AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2013 Issue 4; Ask the Editor
Healthcare Acquired (Nosocomial) Condition
A patient is admitted to the hospital and diagnosed with severe sepsis due to healthcare associated pneumonia. The physician documented that her healthcare associated pneumonia was due to her recent hospitalization. During a recent ICD-10-CM training it was suggested that code Y95 Nosocomial condition could be assigned in addition to R65.20, Severe sepsis without septic shock, and J18.9 Pneumonia, unspecified organism. There is currently no indexing in the ICD-10-CM index that supports this assignment. Is it appropriate to assign code Y95, Nosocomial condition based on the documentation of healthcare associated pneumonia or hospital acquired pneumonia? ...
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Article Overview
This short Find-A-Code article focuses on ICD-10-CM guidance for inpatient documentation that references healthcare-associated or hospital-acquired pneumonia and related severe sepsis diagnoses. It is aimed at coders, CDI staff, auditors, and billers who need to understand how the article frames the use of a nosocomial condition code in this context. The article presents a coding question and discusses the broader issue of indexing support and assignment considerations without serving as a full clinical guide.
Why This Topic Matters
Documentation terms such as healthcare-associated or hospital-acquired pneumonia can affect how an inpatient record is interpreted and coded. Readers benefit from understanding the article’s scope because it addresses a common ICD-10-CM documentation scenario that may influence code selection and review processes.
What You Will Learn
- How the article frames an ICD-10-CM inpatient documentation question involving nosocomial conditions
- What type of documentation language is discussed in relation to healthcare-associated or hospital-acquired pneumonia
- How the article approaches the relationship between a nosocomial condition concept and related diagnosis coding topics
- What broader indexing and assignment concerns the article raises
Who Should Read This
- Medical coders
- Clinical documentation improvement specialists
- Coding auditors
- Revenue cycle staff
- Billers
Codes Discussed
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