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Can you clarify whether advice on documentation issues that do not appear to be specifically tied to a particular coding system (ICD-9-CM nor ICD-10-CM/PCS) are still valid for ICD-10-CM or ICD-10-...
Coding C...
We have noticed discrepancies in the documentation of gestational age for newborns. The obstetrician will document the gestational age in the mother’s record and the pediatrician will document a ...
For the newb...
Term birth is marked on the Newborn Physical Examination sheet. The number of weeks from the mother’s chart (which is put in the baby’s chart) is 41 4/7. The mother’s chart is coded with the ...
No, it would...
The Official ICD-10-CM Guidelines for Coding and Reporting in the chapter on the perinatal period state, “For coding and reporting purposes the perinatal period is defined as before birt...
Yes, the per...
Do two conditions have to be listed together in the diagnostic statement in order to assume an association?
...It is not re...
We are considering developing internal coding guidelines and obtaining medical staff approval to code acute blood loss anemia. The guidelines would specify lab values pre- and post-surgery, as well...
No, it is no...
Can you help with coding disputes with payers when they don’t follow Coding Clinic advice or the Official Guidelines for Coding and Reporting?
...Traditionall...
When coding a physician’s services provided during inpatient hospitalization, which set of coding guidelines is applicable, the inpatient or outpatient guidelines? I’m particularly interested b...
When coding ...
Is it appropriate to report codes for diagnoses recorded as “evidence of cerebral atrophy” and “appears to be a nasal fracture,” when documented on outpatient radiology reports?
...The phrase ...
External causes of morbidity coding may require up to four codes to identify the cause of injury, the intent of the injury (accident versus intentional), the place of injury, and the person’s sta...
Coders shoul...