Cracking the Code

Myocardial infarction (heart attack) occurs when blood flow to the heart is blocked. MIs are classified as acute if the duration is four weeks or less.

Respiratory failure is a life-threatening condition that is always due to an underlying condition. It may be the final pathway of a disease process.

As per the ICD-10-CM guidelines, if we see documented mention of both hypertension and chronic kidney disease

2023 Summary of Revisions to the E/M Code Descriptors and Guidelines Effective January 1, 2023 Inpatient and observation care services

In the medical coding world, there are superficial injuries (i.e. abrasions, contusions, bites, and blisters).

Obstetric patient is admitted to a hospital for complications of pregnancy during one trimester and remains in the hospital into a subsequent trimester

For spinal procedures, a surgeon may complete a laminectomy (decompression) at the same level of a spinal fusion during the same encounter.

It is very important that coders use a patient’s entire medical record to determine the selection of a principal diagnosis

It is important to remember that the intrathoracic injury is sequenced first followed by the rib fracture diagnosis