Health Information Management

Pneumonia with a negative chest x-ray: Clinical diagnoses, physician documentation, and coding guidelines

HIM-HIPAA Insider, November 8, 2011

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As the weather cools, the heat is on coders to properly report the high number of pneumonia cases they tend to see during the winter months.

It's not always easy, considering the changing face of pneumonia testing and treatment and the number of documentation requirements for coding. In particular, cases "without a smoking gun," such as pneumonia without a positive chest x-ray, can be particularly challenging for clinician and coder alike, said Lolita M. Jones, RHIA, CCS, sole principal of Lolita M. Jones Consulting Services in Fort Washington, MD. Jones spoke along with Joy J. King, RHIA, CCS, CCDS, principal of Joy King Consulting, LLC, in Birmingham, AL, during HCPro's September 8 audio conference, "Top ICD-9-CM Trouble Spots: Master Clinical Background and Coding Guidelines for Accurate Coding."
 
However, a solid understanding of both the clinical ­aspects and the guidelines for pneumonia coding can help coders correctly report pneumonia during the long winter months and beyond.
 
Editor’s note: Click here to read the entire article in the November issue of Medical Records Briefing.



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