Agree with Paul on #1 and #2. I have seen Md's document that regardless of negative cultures or findings they are going to treat as that condition or document it as presumed. I think if you have such

He had a Wound Consult with a Wound RN four days later who states: #1 Left

and drain"Prog notes: Surgery POD #1: S/P exploratory laparoscopy and drainage of pelvic abscessAttending: male with hx of perforated appendix s/p appendectomy, treated inpatient with aztreo

and drain"Prog notes: Surgery POD #1: S/P exploratory laparoscopy and drainage of pelvic abscessAttending: male with hx of perforated appendix s/p appendectomy, treated inpatient with aztreo

(5) Pre-op H & H: 11.4 & 34.7, POD #1 H & H : 9.3 & 27.8 POD #2 H & H: 8.4 & 24

Scenario #1:  Patient

Wow.  Thank you for your response.  I'm wondering though, does the provider HAVE to state these were present on admission, presented to ED with...   or can the Pdx be implied sometimes with what the t

(Quote)

#1.  Yes, clarify.  Just because there is bacteremia does not mean that organism is the cause of the pneumonia.  Needs to be a link

If #1 is true, there is no dx or code to be applied. Also, see below reference from Faye Brown regarding reporting mechanical ventilation (I always find myself going back to it and the coding clinics

Thanks Paul - I think your info is coming through.  So if #1 is true, what is the appropriate code if any? 

http://www.webmd.com/a-to-z-guides/rhabdomyolysis-symptoms-causes-treatments#1

is made comfort care rather quickly. Example #1: middle age man with end stage lymphoma and known PNA during inpatient stay changed to GIP status and placed on morphine and Ativan drips. Pt is essent

the codes include codes that would flag for PSI #13 (an elective surgery+sepsis with POA of no), the encoder software recognizes this and then prompts coder to put chart on hold for 2nd level review.

Have any of you had the chance to look at the new FY 2017 Coding guidelines?  There is a new heading under Section I. A. #19. Code Assignment and Clinical Criteria "The assignment of a diagno

Indeed...very difficult!  (Good advice here)(Quote)

Some of the indicators that we include in our queries. #1 Pt went from 1st line of Antibiotics generally Azithromycin and Rocephin and didn't seem to improve and AB was changed to Zosyn or levaquin #

(#1) If a patient falls after admission and is positive for subdural hematoma (HAC), and within several hours declines rapidly and ct shows “massive subdural bleed with midline shift and mass effect w

(#1) If a patient falls after admission and is positive for subdural hematoma (HAC), and within several hours declines rapidly and ct shows “massive subdural bleed with midline shift and mass effect w

(#1) If a patient falls after admission and is positive for subdural hematoma (HAC), and within several hours declines rapidly and ct shows “massive subdural bleed with midline shift and mass effect w