One of the most frequent causes of hospital-acquired AKI is acute tubular necrosis (ATN). Improving documentation and coding practices for ATN involves not only recognizing the condition but also realizing the impact of coding ATN versus AKI, addressing common misconceptions in the HIM field, and fostering collaboration among CDI specialists, coding professionals, and providers. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Research of multiple countries on various continents and with varied complexity of healthcare environments reveals significant disparities in health outcomes and access to healthcare, and a staggering percentage of health outcomes are attributed to social determinants of health. Studying these countries shows differences in how socioeconomic issues are captured in documentation and coded using different patient classification systems, guidelines, and regulations.
ICD-10-CM official guidelines once stated that if there is conflicting documentation in the health record, the documentation of the attending physician supersedes that of any other provider. With that rule now gone, Cheryl Ericson, RN, MS, CCDS, CDIP , helps clarify who should be determining diagnoses.
Postherpetic neuralgia (PHN) is severe pain caused by damage to the nerves at the area or areas affected by shingles after the rash is resolved. Typically, it is pain that persists four or more months after the initial onset of the rash. For documentation purposes, the physician would need to state which type of PHN the patient has. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
Selecting a level of medical decision-making (MDM) is confusing and complicated. In this article, Terry Tropin, MSHAI, RHIA, CCS-P, defines key MDM terms and describes a simplified system for selecting a level of MDM.
Train new coders to follow CMS’ rules when they find CPT guidance that doesn’t match Medicare’s requirements. This article discusses how the CPT manual’s instructions to report modifier -99 (Multiple modifiers) don’t match instructions from CMS and some Medicare administrative contractors.
