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Error 3: Missing the Underlying Cardiac Cause Wrong: Patient with syncope and documented arrhythmia Coded as R55 (principal), I48.91 (secondary) Right: When causation is documented Code I48.91 (principal), R55 (secondary) How to avoid: Always query when a potential causative condition is present Error 4: Failing to Code Orthostatic Hypotension Wrong: Documentation states "orthostatic hypotension" Only R55 coded Right: Documentation states "orthostatic hypotension" Code I95.1 (principal), R55 (secondary) How to avoid: Read the entire medical record, not just the problem list Error 5: Incorrect Sequencing with Injuries Wrong: Patient syncopizes and breaks wrist R55 coded as principal diagnosis Right: Same scenario S52.501A (wrist fracture) principal, R55 secondary, W19.XXXA (fall) external cause How to avoid: Remember that injuries requiring treatment are typically the principal diagnosis

An abdominoplasty (tummy tuck) incision runs from hip to hip

Similar proportion of the two subgroups was in unknown status (16.4% vs

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