Clinical Coding and Physician Documentation Improvement Tips

By Mary Mills RHIT, CCS President & CEO of Documentation Solutions, LLC

Inpatient Coding Tip: Acute Myocardial Infarction

The following are five excluded Major Complications and Comorbidities (MCCs) for AMI patients that expire - MS-DRG 283-285. Review the medical record for alternative MCCs and CCs:

1. Cardiac arrest (code 427.5) – review for PSVT Coding Clinic, 3Q, 1995, p. 9

2.Ventricular fibrillation (code 427.41) – review for ventricular tachycardia (CC) or ventricular flutter (MCC)

3.Cardiogenic shock (code 785.51) - review for acute CHF diastolic/systolic (MCC)

4.Other shock without trauma (code 785.59) – review for sepsis (MCC)

5.Respiratory arrest (code 799.1) – review for acute respiratory failure or pneumonia (MCC)

Inpatient Physician Documentation Improvement Tips
Query physicians concurrently to document
1.The underlying cause of a high or low BMI – Dx: obesity, malnutrition
2.ECHO findings for a) diastolic or systolic dysfunction in CHF patients; b) significance of low EF with only hypohypokinesis documented; c) (? cardiomyopathy)
3.Diagnoses for administration of medications
4.Clarification on diagnoses that were POA
5.Etiology and severity of anemia
6.Significance of abnormal x-ray and lab findings
7.Pathological findings
8.Dehydration with low sodium levels(hyponatremia)
9.UTI patients with chronic indwelling Foley catheters
10.Urosepsis – is patient septic from urosepsis?
11.Etiology of skin ulcers, and specify the site of decubitus ulcers
12.The relationship between pneumonia and organisms on a sputum cultures

Resources: “2008 MS-DRG Workbook” by Documentation Solutions, LLC. (800) 419-6847

www.DocSolutionsLLC.com