The ICD-9-CM guidelines state that it's unusual for two or more diagnoses to meet the definition of principal diagnosis. However, coders know this isn't exactly true, as the scenario tends to occur frequently.
ICD-10-CM/PCS incorporates laterality, acuity, anatomical specificity, and a slew of additional combination and complication codes. Who will submit queries when this information is missing in a medical record? Will coders or CDI specialists take on this role? Perhaps it might be a combination of the two.
Inpatient-only procedures are those that CMS has determined providers must perform on an inpatient basis because they are invasive and require at least 24 hours of postoperative recovery time or monitoring.
