CDI here…What about when obesity is listed in PMH? We have been told need to query for current significance even when current BMI meets criteria. Thank you- have been enjoying your videos!
Thank you! Coders should not be coding anything from the PMH that has the potential to resolve which obesity can. Coders also cannot decide that a patient has or does not have a condition based on clinical criteria like BMI, so yes, I would agree that if the obesity is only documented in the PMH and the physician has not included the diagnosis in their current documentation, a query would be needed to validate if it was still a current diagnosis. I am so glad you asked that question, I wish I would have thought to include that in the video!
Yes, I would. Just be careful of context. Sometimes, in the physical exam, it will be noted as the abdomen is obese. This is not the same as overall obesity. For example, "abdomen is obese." Do not code obesity. For example "56 year old obese male" Do code obesity. I hope that helps!
Hi,claire Pt has pressure stage 2 right foot wound, left side and coccyx wound physician not documented any ulcer then what we have to do either we have to raise query or what we should code for that condition
If I am understanding you correctly, you are saying that the wound care nurse has documented the ulcer but the physician has not? If that is what you meant, yes, you would need to query the physician to validate the ulcer diagnosis. If the physician has documented the pressure ulcer as a diagnosis but has not documented the stage you can code the stage based on the nursing documentation but the ulcer diagnosis itself always must be documented by the physician. I hope that helps!
I am so grateful for these videos especially now with my exam in early June.
Thank you, I am so glad that you find them to be helpful! 😊
CDI here…What about when obesity is listed in PMH? We have been told need to query for current significance even when current BMI meets criteria. Thank you- have been enjoying your videos!
Thank you! Coders should not be coding anything from the PMH that has the potential to resolve which obesity can. Coders also cannot decide that a patient has or does not have a condition based on clinical criteria like BMI, so yes, I would agree that if the obesity is only documented in the PMH and the physician has not included the diagnosis in their current documentation, a query would be needed to validate if it was still a current diagnosis. I am so glad you asked that question, I wish I would have thought to include that in the video!
@@medicalcodingclarified thank you!
You say obesity. What about the term obese? Would you include that as obesity?
Yes, I would. Just be careful of context. Sometimes, in the physical exam, it will be noted as the abdomen is obese. This is not the same as overall obesity. For example, "abdomen is obese." Do not code obesity. For example "56 year old obese male" Do code obesity. I hope that helps!
@@medicalcodingclarified Makes sense! Thank you
😊
Hi,claire
Pt has pressure stage 2 right foot wound, left side and coccyx wound physician not documented any ulcer then what we have to do either we have to raise query or what we should code for that condition
If I am understanding you correctly, you are saying that the wound care nurse has documented the ulcer but the physician has not? If that is what you meant, yes, you would need to query the physician to validate the ulcer diagnosis. If the physician has documented the pressure ulcer as a diagnosis but has not documented the stage you can code the stage based on the nursing documentation but the ulcer diagnosis itself always must be documented by the physician. I hope that helps!
@@medicalcodingclarified
Thank you, Claire.
You're welcome!