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dditional diagnoses can as a pulmonary consultation hematocrit, Haik says. Then,
cause confusion for phy- for atelectasis, says Haik. if theyve done more than rou-
sicians and CDI special- Therefore, one should not tine follow-up of a hematocrit
ists. Whether the concern report isolated radiographic drop (that is more than just
is when they should be reported, or abnormality of atelectasis. daily), one could report drop
what constitutes an additional diag- Therapeutic treatment: For in the hematocrit as an addi-
nosis, William E. Haik, MD, FCCP, example, an oral treatment tional diagnosis.
CDIP, director for DRG Review, Inc., with medication such as Increased nursing care or
in Fort Walton Beach, Florida, says Septra for a urinary monitoring
the general rule is simple. tract infection. Has implications for future
Any condition that affects the Diagnostic procedures: If a healthcare needs: As per the
patients care would be consid- patient has hyponatremia, Official Guidelines for Coding
ered a requirement for reporting and the physician looks at the and Reporting, this applies
a clinically significant additional patients serum cortisol level to newborn coding onlyfor
diagnosis, says Haik, who spoke to work out the cause of the example, delaying the repair
during a January ACDIS webinar on hyponatremia, hyponatremia of a hernia for a few weeks in
the topic. would be reportable as a a newborn.
According to the UHDDS, in order clinically significant additional
for a condition to qualify as a report- diagnosis, says Haik.
Although these are the rules set
able additional diagnosis for coding Extended length of hospital by the UHDDS, Haik says the AHAs
and reporting purposes, it needs to stay: A patient may have a Coding Clinic for ICD-9-CM/ICD-
meet one of the following criteria: gastrointestinal bleed, so 10-CM/PCS offers advice for when
Clinical evaluation: This could the physician monitors and to report additional diagnoses.
include something as simple documents a drop in the The best references for reporting
Complete bilateral vocal cord paralysis CC, 478.34 Not a CC, J38.02