Coding Sample Policies and Forms

Documentation and coding requirements regarding complications

The attached PDF reviews documentation and coding needs for complications and establishes policies and procedures for coders and CDI professionals to follow. Created by Paul Evans, RHIA, CCS, CCS-P, CCDS, the document provides complication definitions, explains when queries should be issued, and explores specific documentation concerns regarding conditions such as incidental serosal tear and postoperative atrial fibrillation.

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Injection and infusion coding examples

Jugna Shah, MPH, and Valerie A. Rinkle, MPA, provide coding answers to four common injection and infusion clinical scenarios.

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ICD-10 sample queries to capture missing diagnoses

These sample queries were adapted from The Clinical Documentation Improvement Specialist's Guide to ICD-10, created and donated by Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director at HCPro in Danvers, Mass.

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Skeletal anatomy quiz

Coders need a strong foundation in anatomy and physiology to code in ICD-10. Find out how well you know your bones with these skeletons.

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ICD-10 sample queries for causative organisms

These sample queries were adapted from The Clinical Documentation Improvement Specialist's Guide to ICD-10, created and donated by Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director at HCPro in Danvers, Mass.

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Required documentation for interventional radiology procedures

This form highlights the required documentation necessary for common interventional radiology procedures, including catheterizations, imaging guidance, and therapeutic interventions. Stacie L. Buck, RHIA, CCS-P, RCC, CIC, of RadRX.com created this form.

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ICD-10-CM sample query

This form provides a sample query for gastritis, which can be coded to a higher specificity in ICD-10-CM. Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director at HCPro, Inc., in Danvers, Mass., provided the form.

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ICD-10-CM Sample Queries

These sample ICD-10-CM queries address establishing the relationship between conditions in ICD-10 t. These queries are adapted from The CDI Specialist’s Guide to ICD-10, created and donated by Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA approved ICD-10-CM/PCS trainer, CDI education director at HCPro, Inc., in Danvers, Mass.

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Interventional radiology decision tree

This interventional radiology decision tree will assist coders in determining whether to code diagnostic angiography/venography, in addition to a therapeutic intervention. Stacie L. Buck, RHIA, CCS-P, RCC, CIC, of RadRX.com created this decision tree.

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Request for Clarification-Confirmation of Diagnosis

This form represents one example of a possible request for diagnostic clarification/confirmation of diagnosis donated by Paul Evans, RHIA, CCS, CCS-P, CCDS.

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Documentation and coding requirements regarding complications

The attached PDF reviews documentation and coding needs for complications and establishes policies and procedures for coders and CDI professionals to follow. Created by Paul Evans, RHIA, CCS, CCS-P, CCDS, the document provides complication definitions, explains when queries are necessary, and explores specific documentation concerns about conditions such as Incidental Serosal Tear and postoperative atrial fibrillation.

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Request for Documentation Clarification ? HIV Status

This query form is a request for documentation clarification of HIV Status. It was submitted by Paul Evans, RHIA, CCS, CCS-P, supervisor of clinical documentation integrity at Sutter Health in San Francisco. It was originally posted on the Association of Clinical Documentation Improvement Specialists website.

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Sample coding/CDI e-blasts for physicians

Hospitals and physicians are transitioning from ­paper and hybrid medical records to EHRs. Because physicians are also requesting electronic versions of other information, such as newsletters, consider keeping them informed about documentation and coding through the use of e-blasts: mass emails sent to physicians. An e-blast should have a subject line that ­captures physicians' attention. Beginning with a greeting such as "Dear Dr. _____" is a matter of personal preference. Use these examples of brief e-blast messages pertaining to CDI from HCPro’s CDI Toolkit to create your own messages.

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Documenting postoperative respiratory failure

This document is a formal approach to documenting postoperative respiratory failure. It is provided by Paul Evans, RHIA, CCS, CCS-P, CCDS, of Sutter Health in San Francisco.

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Condition Code 44 checklist

Before billing an outpatient claim with Condition Code 44, coders need to verify certain information. Deborah K. Hale, CCS, CCDS, president of Administrative Consultant Service, LLC, in Shawnee, Okla, created this checklist of information needed before using Condition Code 44.

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Pneumonia documentation decision tree

This attached pneumonia documentation decision tree, courtesy of Gina Spatafore of Waterbury Hospital, is designed to help physicians document pneumonia, unspecified to the highest degree of specificity. It was originally published on the Association for Clinical Documentation Improvement Specialists website.

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Physician query sample policy

This policy establishes guidelines for inpatient physician queries. It is provided by Donald A. Butler, Manager of Clinical Documentation at Vidant Medical Center in Greenville NC. It was originally published on the Association for Clinical Documentation Improvement Specialists website.

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Establishing cause and effect relationships between diagnoses

This sample query regarding establishing cause and effect relationships between diagnoses was donated by Paul Evans, RHIA, CCS, CCS-P, CCDS, Manager, Regional Clinical Documentation & Coding Integrity, at SutterHealth in San Francisco, Calif. It was originally published on the Association for Clinical Documentation Improvement Specialists website.

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Sample query for UTI due to Foley catheter

Audrey G. Howard, RHIA, and Cheryl Manchenton, RN, BSN, of 3M Health Information Systems provided this example of a query for a documentation of a case involving a urinary tract infection due to insertion of a Foley catheter.

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Documentation clarification form: Respiratory failure

This form includes a clarification request for respiratory failure, including sourced definitions. It is intended as a sample only and any diagnostic criteria should meet the approval of your medical staff.

This is courtesy of Sandy Beatty, clincial documentation specialist for Columbus Regional Hospital. This form originally appeared on the Association for Clinical Documentation Improvement Specialists website.

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Sample orthopedic ICD-10 superbill

This 61-page orthopedic superbill includes ICD-10 and CPT codes and descriptions for a variety of orthopedic services. Roberta Bosank-Cera of Hospitals for Special Surgery, New York, NY, submitted the superbill to the Association of Clinical Documentation Improvement Specialists.

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Level of Care Pocket Card - Inpatient

Deborah K. Hale, CCS, CCDS, president of Administrative Consultant Service, LLC, in Shawnee, Okla, provided this pocket card to use when determining whether a patient should be admitted.

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Level of Care Pocket Card ? Outpatient

Deborah K. Hale, CCS, CCDS, president of Administrative Consultant Service, LLC, in Shawnee, Okla, provided this pocket card to use when determining whether a patient should be placed in observation.

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Request for documentation clarification of pathology findings

This query form is a request for documentation clarification of pathology findings. It was submitted by Paul Evans, RHIA, CCS, CCS-P, supervisor of clinical documentation integrity at Sutter Health in San Francisco. It originally appeared on the Association for Clinical Documentation Specialists website.

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Inpatient wound care sample procedure note

Inpatient coders can struggle with documentation requirements for wound care procedures. Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, and Robert S. Gold, MD, provided this sample wound care procedure note during the HCPro audio conference Inpatient Wound Care Coding: Clinical Information and Documentation Strategies.

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Acute myocardial infarction query sample, updated for ICD-10

ICD-10-CM and ICD-10-PCS should eventually result in better data capture nationwide. The change means healthcare organizations urgently need to educate providers on the importance of improved patient care documentation. The Winthrop University Hospital clinical documentation improvement (CDI) specialists and HIM team have presently implemented a new query for acute myocardial infarctions to help. The newly created forms incorporate the language necessary to capture documentation within these two new areas of enhanced specificity. The team reviewed the queries' content, structure, design, and use to ensure they would be effective and accepted.

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HIV query form

This form can be used to query physicians for additional information for HIV patients. It was submitted by Ameena AbdulMalik of Hermann Memorial Healthcare System in Texas. It was originally published by the Association of Clinical Documentation Improvement Specialists in July.

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Sample coding newsletter for physicians

The HIM team at Cheshire Medical Center/Dartmouth-Hitchcock Keene (N.H.) produces Coding Commentary, a monthly newsletter dedicated to coding and documentation. View a sample of the newsletter and a Q&A with Chris Simons, MS, RHIA, director of HIM and privacy officer at Cheshire. The interview and newsletter originally appeared in the August 2012 issue of Medical Records Briefing.

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Hyperbaric oxygen therapy checklists

Hyperbaric oxygen therapy (HBO) is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. CMS and other payers currently only reimburse for HBO to treat certain conditions. Gloria Miller, CPC, CPMA, vice president of reimbursement services for Comprehensive Healthcare Solutions, Inc., in Tacoma, Wash., provided these checklists to use to prequalify patients for HBO therapy.

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Anatomy and physiology and ICD-10 coding games

Reinforce what your coders are learning as they prepare for ICD-10 with some fun games related to anatomy and physiology and ICD-10 coding subjects. Check out this week’s platinum offering, which includes crosswords, word searches, and matching games to help coders stay engaged.

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Revised physician query for cerebral infarctions in ICD-10

The Winthrop University Hospital clinical documentation improvement (CDI) specialists and HIM team implemented a new query for cerebral infarctions in preparation for the transition to ICD-10. The newly created form incorporates the language necessary to capture documentation within this new area of enhanced specificity.

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ICD-10 Tip Sheets

Gloryanne Bryant, RHIA, CCS, CCDS, regional managing director HIM, NCAL revenue cycle at Kaiser Foundation Health Plan Inc & Hospitals, in Oakland, CA, shares three ICD-10-CM/PCS coding tip sheets:

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Infusion documentation examples

Paula Lewis-Patterson, BSN, MSN, NEA-BC, the clinical administrative director of the ambulatory treatment center at The University of Texas MD Anderson Cancer Center in Houston, provided these and other examples of good and poor documentation for infusions as part of HCPro's audio conference, 2012 Injections and Infusions: CPT Changes, Nursing Documentation Requirements, and Billing Process Review.
 

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ICD-10 Competency Assessment for Coders: Anatomy and Physiology--Integumentary System

This sample of ICD-10 questions about the integumentary system is an excerpt from HCPro’s ICD-10 Competency Assessment for Coders, which is a resource included in the ICD-10 Training Toolkit, a comprehensive tool that provides the building blocks for your training programs for physicians as well as coding, HIM, documentation, and billing professionals in both inpatient and outpatient settings.

Click here for the answer key.

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2012 CDI Pocket Guide

Authors Dr. Richard Pinson and Cynthia Tang provide detailed clinical and coding information regarding heart failure in this excerpt from the Association of Clinical Documentation Improvement Specialists2012 CDI Pocket Guide, a 200+ page pocket manual to help CDI and coding professionals focus on the most common high-volume, high-yield opportunities to improve clinical documentation, coding, and DRG assignment.

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ICD-10 Flashcards

This is a sample of flashcards (part of HCPro’s comprehensive ICD-10 Training Toolkit) related to ICD-10-PCS and obstetrics. The complete set of 124 ICD-10 flashcards can help strengthen your staff members' grasp of ICD-10-PCS as well as root operations.

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Charging for Supplies

Many facilities struggle to determine which ancillary services they can appropriately bill separately for inpatients. Denise Williams, RN, CPC-H, Director of Revenue Integrity Services for Health Revenue Assurance Associates, Inc, in Plantation, FL, provided this sample policy that facilities can use to decide what services to separately bill for inpatients. 

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ICD-9-CM Updates: Readiness Assessment

In order to correctly assign the new ICD-9-CM codes that took effect October 1, it is important for coders to understand both the clinical background and coding guidelines associated with these annual changes. In this assessment, Lolita M. Jones, RHIA, CCS, references a compilation of key clinical and coding guidelines about the revisions, deletions, and additions to ICD-9-CM. The coding guidelines addressed in this assessment are based on the official changes to the tabular list of the ICD-9-CM diagnosis and procedure codes. The clinical guidelines addressed in this assessment are based on the September 2010 and March 2011 minutes of the ICD-9-CM Coordination and Maintenance Committee.

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Device quick reference list

Special billing rules apply when a facility receives a device at no cost, a credit for the full cost of a device being replaced, or a credit equal to at least 50% of the cost of the replacement device. Christi Sarasin, CCS, CCDS, CPC-H, FCS, principal of Sarasin Consulting Group in Friendship, MD, created these lists of codes to flag for special review to determine whether a facility received a device at a reduced cost.

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Outpatient rehabilitation checklists

Physician practices, therapy providers, and facilities are all seeing more outpatient therapy denials. Sharon Bolarakis, CPC, CPC-I, CPMA, provided these three checklists to help you determine if all of the documentation needed for coding and billing is present.

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Audit Checklist: Observation Decision

Elin Baklid-Kunz, MBA, CPC, CCS, director of physician services for Halifax Health in Daytona Beach, FL, provided this checklist to help when auditing for the decision to place a patient in observation.

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Query Process Flow Chart

This sample flow chart illustrates the physician query process from initial query submission through to resolution. Lynne Spryszak, RN, CCDS, CPC-A, CDI education director at HCPro, Inc., in Danvers, MA, included this chart in her 2010 audio conference presentation "Physician Queries Workshop: Tools and Techniques for Compliant, Effective Clarification."

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ICD-10 fracture extension codes

Lolita M. Jones, RHIA, CCS, principal of Lolita M. Jones Consulting Services in Fort Washington, MD, provided this handy reference to help coders select the appropriate seventh character for ICD-10 fracture codes.

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Injections and infusions coding examples

These injections and infusions coding examples were created by Jugna Shah, MPH, president of Nimitt Consulting in Washington, D.C. for HCPro’s January 19, 2011 audio conference, “Injections and Infusions: Solutions for Common Coding and Billing Questions.”

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ICD-10-PCS flashcards

ICD-10 implementation will be costly for hospitals. But teaching coders the root operations for ICD-10-PCS coding doesn’t have to be. Simply cut on the dotted lines of this handy set of flashcards, which were featured in a recent issue of Medical Records Briefing. On one side, you’ll see the various root operations; the other side lists their corresponding definitions and provides examples and other relevant information coders should know about the terms.

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Sample query for unspecified chest pain

Susan A. Klein, BSN, RN, C-CDI, director of clinical documentation management at Saint Peter's University Hospital in Monroe Township, NJ, provided this sample query to HCPro’s Association of Clinical Documentation Improvement Specialists (ACDIS). Note that best practice regarding query templates is to include your own facility medical staff in their creation and to vet them with your facility coding, compliance, and legal team. In general, it is best practice to have the CDI task force work across various departments to develop queries. The ones provided on the ACDIS website are donated by members to serve as templates.

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Endovascular revascularization coding tool

CPT® codes 37220–37235 are to be used to describe endovascular procedures performed percutaneously and/or through open surgery exposure  for occlusive disease. Lolita M. Jones, RHIA, CCS, principal of Lolita M. Jones Consulting Services in Fort Washington, MD, and an AHIMA-Approved ICD-10-CM/PCS Trainer, created this tool to help coders determine the correct code forendovascular revascularization.

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Severity of illness for various conditions: Clinical definitions

This tool from the Physician Documentation Improvement Pocket Guide, which you can share with your physicians, contains clinical definitions for the severity of illness of multiple commonly missed documentation improvement opportunities.

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Error point system for auditing evaluation and management codes

When performing chart audits, especially those involving CPT® and evaluation and management codes, there are a number of ways in which you can determine error rates. One method is using a point system, which places a weighted point for each type of finding. Joe L. Rivet, coding compliance specialist at Hall, Render, Killian, Heath & Lyman in Troy, MI, shares this sample error point system for determining coding error rates. Typically the higher the weight, the more significant the error. The facility would need to determine what is an acceptable point level for passing and audit.
 

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Sample physician query tracking spreadsheet

Rose T. Dunn, MBA, RHIA, CPA, FACHE, shares a physician query tracking spreadsheet in The Coding Manager’s Handbook to help you track the query process by having users capture important data, including the reason for the query, the physician queried, the coder or clinical documentation specialist who initiated the query, as well as the DRG or APC before and after clarification from the physician.
 

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Tip sheet for pediatrician documentation

Pamela P. Bensen, MD, MS, FACEP, shares this checklist that you can use to communicate documentation requirements to pediatricians.

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Appeal letter for denials due to unbundling

Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, an independent coding consultant in Melba, ID, shares this sample appeal letter for denials due to charges the payer states should have been bundled instead of charged separately.  

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CPT Coding resource: Lesion Excision

Lolita M. Jones, RHIA, CCS, owner of Lolita M. Jones Consulting Services in Fort Washington, MD, developed this chart to assist coders in choosing the correct excision code.

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Inpatient Physician Query Process

This Inpatient Physician Query Process form outlines a sample policy for querying physicians to clarify physician documentation whenever there is conflicting, ambiguous, or incomplete information in the medical record regarding any significant reportable condition or procedure. Learn more about HCPro’s Physician Queries Handbook by Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS, James S. Kennedy, MD, CCS, Marion Kruse, MBA, RN, and Lynne Spryszak, RN, CPC-A, CCDS, at the Healthcare Marketplace.

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Evaluation and Management Audit Tool

Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, an independent coding consultant in Melba, ID, shares this tool for auditing E/M codes and assigning the appropriate level code.

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History of Present Illness Reference Tool

Use this sample reference tool to determine the chronological development of a patient's current illness from the beginning or from the previous encounter to the present. Michelle Solomon, BA, LPN, CPC, revenue team manager of primary care at Henry Ford Health System in Detroit provided this sample tool.

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Injections and infusions handout

Ensuring accurate capture of injection and infusion administration and drug codes is an important part of ensuring your facility receives the reimbursement it deserves. Sharon Clayton, RN, MS, MBA, CPC, president of Key Healthcare Consulting, LLC, provided this sample injection and infusion handout to help with coding accuracy.

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Sample query form for chest pain

Use this sample query form for chest pain when you need more specific documentation from physicians. James S. Kennedy, MD, CCS, director at FTI Healthcare in Atlanta provided this sample form.

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Sample query form for heart failure

Use this sample query form for heart failure when you need more specific documentation from physicians. James S. Kennedy, MD, CCS, director at FTI Healthcare in Atlanta provided this sample form.

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Sample query form for malnutrition

Use this sample query form for malnutrition when you need more specific documentation from physicians. Faye Anderson, RHIA, division director for HIM at Southeast Alabama Medical Center in Dothan, AL, provided this sample form.

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Sample Template for Initial Preventive Physical Examination

Lori-Lynne Webb, CPC, CCS-P, CCP, an independent coding consultant in Melba, ID, shares this sample template for an initial preventive physical examination (IPPE). This can be a handy tool to ensure that physicians don’t overlook IPPE requirements.

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Sample postoperative pain injection form

This form, which is an excerpt from HCPro’s book, Orthopedic Coding Guide for Ambulatory Surgery Centers, Second Edition by Lolita M. Jones, RHIA, CCS, is a sample postoperative pain injection form that one surgery center developed to ensure comprehensive postoperative pain control documentation. For more information, please visit HCMarketplace.com

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Care Plan at risk for Pressure Ulcers

Care Plan at risk for Pressure Ulcers

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Medicare Part B 2008 HCPCS and modifier annual update chart

Medicare Part B 2008 HCPCS and modifier annual update chart by Lori-Lynne Webb, CPC, CCS-P, CCP, independent coding consultant located in Melba, ID.

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Sample policy on standardizing E/M audits

Sample policy on standardizing E/M audits

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Audit results

Audit results

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Clinical Documentation Request

The form is used to measure a patient's degree of malnutrition.

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Blue card: Bacteremia sepsis

HCPro's Association of Clinical Documentation Improvement Specialists (ACDIS) present a Blue chart designed to help clinical documentation of Bacteremia sepsis. If you aren't an ACDIS member but would like to become one, or if you would like to learn more about ACDIS visit the ACDIS Web site at http://www.cdiassociation.com/

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POA query form

HCPro's Association of Clinical Documentation Improvement Specialists (ACDIS) present a Present on Admission (POA) query form designed to help clinical documentation improvement specialists identify whether an associated condition was present at the time of the order for an inpatient admission. If you aren't an ACDIS member but would like to become one, or if you would like to learn more about ACDIS visit the ACDIS Web site at http://www.cdiassociation.com/

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Heart failure chart

HCPro's Association of Clinical Documentation Improvement Specialists (ACDIS) present a heart failure chart designed to help clinical documentation improvement specialists identify signs and symptoms of heart failure in the medical record. If you aren't an ACDIS member but would like to become one, or if you would like to learn more about ACDIS visit the ACDIS Web site at www.cdiassociation.com

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Fifth digit classification table

A fifth lymphatic and hematopoietic tissue category code digit denotes a specific location where the lymphoma occurs. For example, lymphoma can occur in any one of the following locations on the body:

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Sample coding career ladder

When managers propose coder compensation levels to an organization's human resource department, they typically take into account both credentials and experience. For this reason, most HIM departments implement a coding career ladder that outlines objective and measurable criteria for advancement. The criteria must also define proficiency and can be tied to production expectations developed for the department. The following is one example of a coding career ladder. Consider implementing a similar system in your hospital if you don't already have one in place.

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Acute respiratory failure documentation prompter

Use this acute respiratory failure documentation prompter to help prompt physicians to document language that will affect severity-adjusted DRGs.

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Cardiovascular prompt card

Use this card to help prompt physician documentation for various cardiovascular conditions.

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Cardiac CCs

Use this prompter to help capture cardiac CCs.

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Nephrology Attending Evaluation

Use this nephrology attending evaluation to track patients' condition. Source: Oregon Health & Science University, Portland. Reprinted with permission.

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Discharge summary/discharge order form

Use this nifty form to track discharges, final diagnoses, and more. Source: North Kansas City (MO) Hospital. Reprinted with permission.

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Record review for H&Ps

Use this chart to ensure that critical elements appear on your history and physical forms. Source: Adapted from: Ongoing Records Review, Third Edition: A Guide to JCAHO Compliance and Best Practices, Coyright 2003, HCPro, Inc.

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Signature identification form

Use this form to help clarify physician signatures in the medical record. Source: Medical College of Ohio Hospitals. Reprinted with permission.

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Query tracking sheet

Use this form to track queries as well as post-query payments. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-1047.html

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Respiratory failure clarification tool

Use this tool to clarify respiratory failure and query physicians for documentation improvement. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit: http://www.hcmarketplace.com/prod-1047.html

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Cardiology doc pocket tool

This pocket guide for cardiology physicians includes common cardiology DRGs, common cormorbidities, and common conditions of catheterization patients. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-1047.html

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Denial appeal letter

Use this sample letter when appealing denials at your facility. Source: Denial Management: Key Tools and Strategies for Prevention and Improvement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-3659.html

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Documentation content/quality deficiency form

Use this form to track documentation and quality deficiencies. Source: Adapted from: Seven Steps to HIM Compliance, copyright 1998 HCPro, Inc.

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Facility E/M guidelines based on a point system

These facility E/M guidelines use a point system to determine each level of care. Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission. For More information visit: http://www.hcmarketplace.com/prod-1740.html

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Facility E/M guidelines based on staff interventions

These facility E/M guidelines use staff intervention to determine each level of care. Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission. For More information visit: http://www.hcmarketplace.com/prod-1740.html

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Facility E/M guidelines based on staff time

This set of facility E/M guidelines uses time as a determining factor for each level of care. Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission. For More information visit: http://www.hcmarketplace.com/prod-1740.html

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General Progress Note Template

Use this template for a general progress note. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-1047.html

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Observation services guidelines

These observation services guidelines define observation, explain average lengths of stay, outline what observation excludes, explain necessary documentation, and discuss medical neccesity. Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission. For More information visit: http://www.hcmarketplace.com/prod-1740.html

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Metric template

Use this sample metric template for RVUs, uncollectable AVRs, and registration processes. Source: Revenue Cycle Management: A Best Practices Toolkit, reprinted with permission For more information visit: http://www.hcmarketplace.com/prod-4003.html

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Pneumonia query form

Use this sample pneumonia query form to ensure accurate data reporting for your facility or practice. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-1047.html

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Unapproved abbreviations review tool

Disseminate this list to your coding staff so that they may track physician usage of unapproved abbreviations. Source: Ongoing Records Review, Fifth Edition: A Guide to The Joint Comission Compliance and Best Practices, reprinted with permission. For more information visit: http://www.hcmarketplace.com/prod-5043.html.

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