Welcome to Coffee with the Coder^®, our conversation with Paula Digby and her team to address issues, observations and questions for Health Information Management professionals, physicians, auditors, payors and students. You are invited to listen in for ten to twenty minutes every other Monday and to submit your favorite questions or comments for Coffee with the Coder^® To receive text notifications send an email to help@AQ-IQ.com with your request. We will text you in the hour prior to the start of the next episode.

Ms Digby begins the “Insiders” portion by telling of her own experience with a traumatic brain injury. She refers to this resource and discusses aspects of brain injuries. 

First, we speak to how much documentation is required to report a particular diagnosis as chief complaint, is prescribing medication sufficient? In some practices, several meds are injected in multiple sites subcutaneously. How would we bill the J codes, per injection or per substance? Is “low blood sugar” written by the provider in the chart of a diabetic patient sufficient to report diabetes with hypoglycemia? Lastly, when a patient enters IRF for Multiple Trauma after experiencing a CVA during the acute stay, how do we capture the CVA?

Congratulations to Penny for winning the “mugging”!

Dial in for the next Episode on April 12 beginning at 10:10 am Eastern (7:10 am Pacific).