Coding and CDI Tips
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Coding and CDI Tips
Coding Tips: Medicare Inpatient Hospital Billing Review for Sepsis
OIG Workplan: Review Medicare Inpatient Hospital Billing for Sepsis The OIG will be reviewing Medicare claims to assess patterns in the inpatient hospital billing of sepsis in 2023 and describe how the billing of sepsis varied among hospitals. The definition of and...
Coding Tips: Dural Tear Clarification
Dural Tear Clarification Per Coding Clinic, First Quarter 2024: A dural tear is clinically significant and should always be reported when documented by the provider. G97.41, accidental puncture or laceration of dura during a procedure is a CC...
CDI Tips: Atrial Fibrillation (AF)
Atrial Fibrillation (AF) Paroxysmal AF Definition: Episodes terminate either spontaneously or with treatment within 7 days; may recur Persistent AF Definition: AF is continuous and lasts > 7 days, fails to terminate spontaneously Long-standing Persistent AF...
Coding Tips: Myocardial Infarction with Angina
Myocardial Infarction with Angina Per Coding Clinic, First Quarter 2024: Is it appropriate to assign a code for CAD with angina for the severe native multi-vessel disease that resulted in the MI? Examples: Assign code I21.4: Non-ST elevation (NSTEMI) myocardial...
Coding Tips: Underdosing
UnderdosingPer Coding Clinic, First Quarter 2024: Underdosing when a PRN medication is not taken Example: Documentation states: A patient presents to the ED with shortness of breath due to an exacerbation of asthma. The patient did not take his PRN medication,...
CDI Tips: Debridement
Debridement Excisional Debridement Definition: The surgical removal or cutting away of devitalized tissue, necrosis, and slough. Non-Excisional Debridement Definition: The nonoperative brushing, irrigating, scrubbing, or washing of devitalized tissue, necrosis,...