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Clinical & Coding
I am new to the cdi world, so bear with me.
I see a lot of sbo, and sometimes there's specificity as to type, but not cause. Should I be querying for cause and or capture symptoms? What is the best way to capture this?
Yes, query for the cause only if you have clinical indicators that are pointing to a cause of the SBO, such as Crohn's disease, carcinomatosis, etc. If you have clinical indicators to support it being either partial or complete, you can query for the type as well. The code book has an Excludes 1 note under unspecified bowel obstruction "intestinal obstruction due to specified condition-code to condition", so if a SBO is due to another condition, then we code that condition instead.