Often in emergency and acute care healthcare settings, we find patients with a diagnosis of “Respiratory Failure.” Clinical coding and clinical documentation improvement (CDI) professionals need to have a strong knowledge and understanding of both medical/clinical aspects of diseases as well as the coding guidelines and rules. This blog includes a brief discussion of the clinical aspects and ICD-10-CM coding of Respiratory Failure.

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.

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.