CODING TIPS

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CODING TIPS

• Terence Shum, MD
• Coding Champion
• 2008

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Atherosclerosis of Aorta

• Look for the finding in xray report
• Go back to do addendum and code it
• Code them during the office visit or hospital
  visit
• Patient should be treated to lower their
  cardiovascular risks, i.e. smoking cessation,
  life-style modificaion, put on asa, statins,
  ACEI/ARB.

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Document all CHRONIC Diagnoses in the HP and D/C
Summary - Along with the ACUTE Diagnosis

• Example
• Diabetes with Diabetic Complications
• Hx of old MI, Stable Angina, CHF
• PVD
• COPD, Chronic Respiratory Failure
• CVA (w/ or w/o Hemiparesis)

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Link diabetic complications to diabetes if there
is no other cause.

• Examples
• Diabetic Microalbuminurea
• Diabetic CKD (stage 1-5)
• Diabetic ESRD
• Diabetic Neuropathy
• Diabetic Retinopathy
• Diabetic PVD, Gangrene or Ulcer
• Diabetic E.D.
• Diabetic Gastroparesis

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• Describe Diabetic complications as
• Due to Diabetes
• Secondary to Diabetes
• Diabetic
• Do not use DM neuropathy, etc.

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Specify the type of Pneumonia

• Document Aspiration Pneumonia if pt has
• 1) ALOC, found down, syncope, CVA, lethargy,
  known swallowing risk
• 2) SNF/NH pt
• 3) Drug O.D.
• 4) Post-op,
• 5) Post CPR/code,
• 6) Hx of prior aspiration pneumonia

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Link culture results to the pneumonia if
appropriate

• Example
• Pneumonia due to Streptococcal Pneumonia
• You can do addendum post-discharge.
• You will be queried on this.

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Acute Respiratory Failure

• Document Acute Respiratory Failure if pt has
• PO2 lt 60 (normal lung)
• PO2lt 50 ( for COPD)
• PO2 gt50 w/ fall in pH
• Pt needs supplemental O2 or Ventilator support

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Chronic Respiratory Failure

• Document Chronic Respiratory Failure if patient
  needs to use home O2

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Malnutrition

• Document Malnutrition when pt is
• 1) Underweight lt90IBW
• or lose 10 of current wt.
• Poor oral intake
• Requires TPN/PPN/tube feeding
• Albumin lt 3.0
• prealbumin lt 12
• think about pressure ulcer!!!

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DO NOT USE

• Urosepsis--- use Sepsis due to UTI
• Bacteremia--- use Septicemia or Sepsis

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Sepsis

• Document Sepsis when pt has an infection plus
  any two of the following
• Temp gt38C or lt36C
• HR gt90/min
• RR gt20/min or pCO2lt32
• WBC gt12K or lt 4K or 10 bands
• Do not use bacteremia or urosepsis

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Severe Sepsis

• Document Severe Sepsis when there is end organ
  failure
• Respiratory failure
• Acute renal failure
• ALOC
• Metabolic-lactic acidosis

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Septic Shock

• Document Septic Shock when there issepsis
  with
• 1) Hypotension BPslt 90
• 2) Pt requires vasopressor

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Anemia

• Specify the type of Anemia
• 1) Acute or Chronic
• 2) due to GI bleed? Any ulcer or H. Pylori?
• 3) post-op blood loss
• 4) due to ESRD, MDS etc.

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ALWAYS CODE

• Amputation Status(even a toe)
• Ostomy Status
• Dialysis Status(even w/ the shunt, but not on
  dialysis yet)
• Organ Transplant / Replacement Status
• HIV Positive Status

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Look for decubitus

• Very common in hospital patients(20)
• Photos by nursing staffs as a clue
• Document dx and use pre-print order for tx plan
• Think about Malnutrition
• Look for high risk pts
• Pt with malnutrition
• Pt from SNF/NH
• Immobile pts---CVA, quadriplegia
• Hip fx, post-op