Dear Medical Coder,

Over the past few days I’ve become more short of breath with wheezing and productive cough, probably due to all this grass pollen.  I should tell you that I do have COPD.  Should I tough it out or go see a doctor?

– Dyspneic in Dallas

34237650_mDear Dyspneic,

The best part about ICD-10 is that there are thousands upon thousands more codes.  Isn’t it wonderful?  Were you bitten by a shark?  We have three codes for that!  Or were you struck by a shark?  Because we have three codes for that too!  It’s a golden time to be a medical coder, I absolutely LOVE IT!  And since I love it, our providers must love it too!  I particularly love the codes on macaws and roller-skates.  This is what medicine is all about!

Dear Medical Coder,

I’m at the bedside with my husband and he just stopped breathing!  They’ve called a Code Blue!  Is there anything I can do to help?!

– Concerned in Charleston

Dear Concerned,

In times like these, it is absolutely critical when a patient has an infection to document if that patient meets criteria for SIRS or sepsis.  Avoid using the term “urosepsis” since that codes down only to urinary tract infection (UTI), whereas “sepsis due to UTI” is a better term.  Now, check your inbox.  I have sent you a query.

Dear Medical Coder,

I’m having 8 out of 10 chest pain, worse with exertion, improved with rest, and associated with shortness of breath.  I just had a stress test that was normal.  What would you advise?

– Angina in Austin

Dear Angina,

Clinical Documentation Query #1: Your note mentions heart failure, but that’s it.  Can you be more specific?  Is it acute?  Or is chronic?  Or is acute on chronic?  Or is it chronic on acute?  Or could it be acute on subacute on chronic?  Is it diastolic heart failure, systolic heart failure, both, neither, one, or three out of four?  What year was the diagnosis?  What month?  What was he eating?  Pizza?  If so, it’s not documented.  Please respond.  Query #2: It has been well over 2 minutes since my initial query and I am disappointed that you have not responded to the query or barrage of pages.  I don’t want to hear any excuses about “evaluating the patient” or “calling cardiology.”  I must know the status of his heart failure and pizza.  Don’t make me overhead page you.  Query #3: It has been 30 seconds since my second query and still no response since you are “calling to get an ICU bed.”  I have queried your friends and loved ones.  (Gosh, these providers, they are so FRUSTRATING!!!  ARGHHHHH!!!!!!!!!)

Stephanie Reynolds is a coding specialist and is eagerly awaiting your responses to her queries, even if you had no involvement in the care of the patient in question.

Need some more advice?
Ask a 4th-Year Med Student (Who’s Checked Out for the Year)
Ask a Hospitalist
Ask a July 1st Medicine Intern
Ask a Surgical Intern, Part 1
Ask a Surgical Intern, Part 2



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