Gloryanne Bryant, RHIA,CDIP, CCS, CCDS, AHIMA ICD-10-CM/PCS Trainer 12/31/19 Gloryanne Bryant, RHIA,CDIP, CCS, CCDS, AHIMA ICD-10-CM/PCS Trainer 12/31/19

Sepsis Documentation and Coding Guidelines (2020 Update)

We know that SEPSIS is a life-threatening condition and there has been much discussed about this subject in many clinical circles as well as in clinical coding and clinical documentation improvement (CDI). The golden rule for the HIM Coding and CDI professional is that we must have the diagnostic documentation by the provider in order to assign the ICD-10-CM code(s) and follow Official Guidelines.

Robyn Petersen, RHIT, CPC, CCS, CPMA 6/12/18 Robyn Petersen, RHIT, CPC, CCS, CPMA 6/12/18

Tips for Documenting and Coding Injections and Infusions

Avoiding claims denials requires compliance with coding guidelines. In CPT, a common area of noncompliance is the documentation and coding of injections and infusions. The Emergency Room is one service area wherein injections and infusions are common treatments for a multitude of diagnoses.