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- 12%: Fewer than three records
- 30%: Three records per hour
- 14%: 3.5 to 3.75 records per hour
- 10%: Four records per hour
- 6% Greater than four records per hour
- 29%: Not applicable
The present-on-admission (POA) indicator refers to conditions that are present at the time an order for inpatient admission occurs. Coders should report a POA indicator for a principal diagnosis, as well as any secondary diagnoses or E codes.
To assign POA, coders must rely on a treating physician’s documentation. Assuming physician documentation is accurate and complete, a coder can consider these tips when assigning a POA indicator: Read More→
Q: A patient came into the ER with complaints of a headache and facial pain. The ER physician gave a final diagnosis of sinusitis. This patient had no history of sinusitis. After a coding review, the reviewer said we were wrong to use “acute” and told us to use “chronic.” She told us never to use “acute” unless the physician documents the condition as “acute.” We were previously under the impression that when coding ER accounts, coders should always report conditions as “acute.” Do you know of any ER coding guidelines or publications that would clear this up?
Follow these steps when researching an ICD-9-CM coding question:
- Start with the ICD-9-CM Manual. You can resolve many ICD-9-CM coding questions by carefully studying the ICD-9-CM Manual itself, paying particular attention to typographical conventions and the various notes included throughout the Manual.
- Review the official guidelines. The Public Health Service and CMS jointly publish the Official ICD-9-CM Guidelines for Coding and Reporting. The following organizations helped develop and approve these guidelines:
- American Hospital Association (AHA)
- AHIMA
- CMS
- National Center for Health Statistics
- Review Coding Clinic. Coding Clinic is a newsletter published by the AHA. Representatives from the four organizations listed above review and approve each issue of Coding Clinic. You can order a subscription or back issues of Coding Clinic from the AHA by calling 800/AHA-2626.
This tip was adapted from the handbook, Coding and You: What Every Healthcare Professional Should Know. For ordering information, visit the HCMarketplace.
It’s important for hospitals to have a process in place regarding never events, says John Steiner, Esq., chief compliance officer at UK HealthCare in Lexington, KY.
“There are numerous support areas that need to figure out how to work together—risk management, compliance, legal, patient accounts, coding, etc.,” he says.
There are several steps providers can take to ensure they are prepared, Steiner says: Read More→
Q: A patient undergoes outpatient surgery and is subsequently admitted due to acute blood loss anemia with hemorrhage and low hematocrit and hemoglobin caused by Plavix®. A physician had instructed the patient to discontinue this medication 10 days before surgery. However, the patient admits after surgery that he or she stopped taking the drug only two days before surgery.
What ICD-9 code(s) should I report for this scenario? Read More→
A new study shows Medicare’s policy against paying for hospital acquired conditions (HAC) will only save the $400 billion program $1.1 million to $2.7 million.
California researchers conducted the study, according to a Wall Street Journal article. The researchers studied discharge data from California Medicare beneficiaries in 2006, looking for six conditions the authors deemed definable, according to the article. Out of the total 767,995 cases, there were 828 cases of those conditions, and 26 would have been subject to lower payments.
The following ICD-9-CM codes denote acute respiratory failure (ARF):
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518.81, ARF
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518.82, other pulmonary insufficiency, not elsewhere classified (includes acute respiratory distress, acute respiratory insufficiency, and adult respiratory distress syndrome NEC)
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518.84, acute and chronic respiratory failure
Check out Coding Clinic, fourth quarter 1998 and first quarter 2005, for more information about when ARF should be the principal diagnosis, as well as documentation requirements.
The sequencing of respiratory failure depends on the reason for admission. When respiratory failure from an underlying condition causes the inpatient admission, the failure becomes the principal diagnosis; when the patient develops respiratory failure after admission, it is the secondary diagnosis and should be coded as such.
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