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Inpatient Facility Coding & Compliance Alert

Reader Question:

Know Whether Asking for 'Grade' Details Will Affect CC or MCC

Published on Mon Dec 17, 2012

Question: Many of the physicians at our hospital document "grade" patient injuries (such as "grade 4 liver laceration," but don’t include other specifics. Should we be querying the physicians on this?
California Subscriber Answer: From an inpatient coding standpoint, you don’t need to query the physician about the grade of laceration. However, you do need to know what caused the laceration (trauma, an accidental laceration during surgery or another procedure, etc.). Knowing the cause will lead you to either the E codes or any 900 code/complication. Sticking point: Some coding software programs ask for levels of laceration or injury, which helps tip the scale toward a complication/comorbidity (CC) or major complication/comorbidity (MCC). If that’s the case, educate the physicians to what coders need in order to code most accurately.
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