Q: Is it appropriate to assign ICD-10-CM code Y95 (nosocomial condition) based on the documentation of healthcare-associated pneumonia (HCAP) or hospital-acquired pneumonia (HAP)? It is appropriate to assign the code for documented healthcare-associated conditions. Should this still be queried for specificity, and should the hospital-acquired condition (i.e., pneumonia) be coded as bacterial, viral, or something else?
CMS recently released the 2017 ICD-10-PCS code updates and guidelines, which include changes to certain root operations. Of the updates, the most notable modifications are the addition of root operation Perfusion, and edits to the current definitions of Control and Creation.
Q: When a patient presents with acute respiratory failure, as well as an overdose, is it ever appropriate to assign the acute respiratory failure as principal diagnosis, since it is an acute condition that would have occasioned the admission to the hospital?
Paul Evans, RHIA, CCS, CCS-P, CCDS, give coders ICD-10-PCS documentation and coding tips for three of the most common, and commonly misunderstood, procedures performed via bronchoscopy.
Since the physician doesn't need to document a specific root operation, coders cannot rely solely on the terms the physician uses; thus it is important for each coder to fully understand each root operation, especially Control and Repair. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, address the inpatient side of bariatric surgery, and how obesity and body mass index play a role in coding.
Shannon Newell, RHIA, CCS , AHIMA-approved ICD-10-CM/PCS trainer, writes about significant changes to PSI 90 in the 2017 IPPS proposed rule, one of which is a new name–The Patient Safety and Adverse Events Composite.
Q: I am never sure of correct sequencing when the admission is for flu, pneumonia, and asthma. Can you suggest proper sequencing, and if queries are needed?
Michelle M. Wieczorek, RN, RHIT, CPHQ, discusses how documentation and coding can impact your facility’s data reported for hospital-acquired conditions and present on admission indicators.
