HCPro, JustCoding Inpatient - 2015 Issue 4 (January)
Q&A: Atelectasis query for secondary diagnosis
January 28th, 2015
Subscribe or sign in to view the full article.
Article Overview
This article addresses how to evaluate an imaging finding in the context of a hospital encounter and whether related documentation supports reporting a secondary diagnosis. It is aimed at coding, CDI, and hospital documentation professionals who need general guidance on assessing clinical significance, routine conditions, and query appropriateness under inpatient reporting criteria.
Why This Topic Matters
Accurate secondary-diagnosis capture depends on distinguishing incidental or integral findings from clinically supported conditions that affect care, documentation, and query workflows.
What You Will Learn
- How secondary-diagnosis support is assessed in the setting of abnormal diagnostic findings
- What general criteria are considered when determining whether a condition is reportable
- How CDI professionals think about routine postoperative findings and provider clarification
- When clinical significance and documentation support may warrant a provider query
Who Should Read This
- Clinical documentation integrity specialists
- Inpatient medical coders
- Coding auditors
- Hospital HIM professionals
- Nursing documentation reviewers
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com