HCPro, JustCoding Inpatient - 2016 Issue 37 (October)
Q&A: Sequencing for flu, pneumonia, and asthma
October 4th, 2016
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Article Overview
This Q&A reviews how coders and CDI professionals should think about diagnosis sequencing and documentation clarification when influenza, pneumonia, asthma, and possible respiratory failure or sepsis appear in the same admission. It is aimed at coding and clinical documentation improvement staff who need to understand when provider queries may be appropriate and which general guideline areas and code sets are implicated.
Why This Topic Matters
The article helps readers recognize when documentation may be insufficient for accurate principal diagnosis selection and when additional clarification can affect coding, DRG assignment, and severity capture.
Article Sections
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Question
The question presents an admission involving respiratory symptoms and multiple documented respiratory diagnoses. It asks about sequencing and whether queries are needed.
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Answer
The response discusses general sequencing and documentation review considerations for influenza, pneumonia, asthma, respiratory failure, and possible sepsis. It also references applicable guideline areas and the need to assess provider documentation for clarification.
What You Will Learn
- How this type of admission is approached from a diagnosis sequencing perspective
- Why provider documentation clarification may be needed in respiratory cases
- How broad coding guideline areas can affect principal diagnosis selection
- What kinds of documentation elements may influence coding and DRG assignment
Who Should Read This
- Medical coders
- Clinical documentation integrity specialists
- Coding auditors
- HIM professionals
Codes Discussed
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