medical codig guidelines tool

MedCode Assistant

Professional Guideline & Productivity Tracker

Daily Tracker

Charts Completed 0 / 50

Quick Resources

• ICD-10-CM Guidelines
• AHA Coding Clinic

Guideline Quick-Peek

FY 2024

Sepsis & SIRS

Critical

Underlying infection sequenced first, followed by severe sepsis (R65.2-). Code organ dysfunction separately.

HCC Logic (MEAT)

Risk Adj

Conditions must be Monitored, Evaluated, Assessed, or Treated during the encounter to be coded for risk adjustment.

Principal Dx Sequencing

General

Condition established after study to be chiefly responsible for occasioning the admission to the hospital.

Neoplasm Guidelines

Specialty

If treatment is directed at the malignancy, designate the malignancy as principal. If directed at secondary site, secondary is principal.

No guidelines found

Try adjusting your search terms.

Sepsis & Septic Shock

Sequencing

Whether Sepsis is present on admission (POA) or develops later dictates sequencing. If POA and meets Principal Diagnosis criteria, sequence the underlying systemic infection first (e.g., A41.9).

Severe Sepsis

Requires a minimum of two codes: first the systemic infection, followed by R65.2- (Severe Sepsis). Additional codes for acute organ dysfunction must be reported.

Septic Shock

Indicates severe sepsis with acute circulatory failure. Code first the systemic infection, followed by R65.21 (Severe sepsis with septic shock), and any associated organ dysfunctions.

Coding Tip Never assign R65.2- (Severe Sepsis) as a principal diagnosis.

HCC Risk Adjustment (MEAT)

To capture HCCs, the provider must explicitly document that the condition was addressed using MEAT criteria:

M - Monitor Signs, symptoms, disease progression, or regression.

E - Evaluate Test results, medication effectiveness, response to treatment.

A - Assess Ordering tests, discussion, review records, counseling.

T - Treat Medications, therapies, other modalities.

History of (Z codes) conditions generally do not risk adjust unless they are active conditions requiring ongoing management (e.g., active cancer vs. historical).

Principal Diagnosis

"The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."

• Two or more equal diagnoses: Either may be sequenced first when neither the Index nor Tabular List provides direction.
• Treatment directed at secondary: When admitted for a primary condition but treatment is only directed at a secondary condition, the primary condition is still sequenced as principal.
• Exception Admissions for specific treatments like chemotherapy (Z51.11) require the Z code to be sequenced first.

Neoplasm Guidelines

Treatment directed at Primary Site Designate the primary malignancy as the principal diagnosis.

Treatment directed at Secondary Site Designate the secondary site malignancy as the principal diagnosis, even though the primary malignancy is still present.

History of Malignancy When a primary malignancy has been previously excised/eradicated, and there is no further treatment directed to that site, use personal history code (Z85.-).