William E. Haik, MD, FCCP, CDIP, writes that complex pneumonias can segregate to a higher-weighted MS-DRG than other pneumonia types, so reviewing clinical elements with your physician staff may help improve documentation and avoid adverse determinations by external reviewers for these conditions.
Inpatient coding audits need to be tailored to the type of record being reviewed, the time it may take to complete the audit, and any compliance-related issues that may crop up. This article focuses on how coding managers can streamline these aspects to ensure a successful audit. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
A nine-month audit conducted by a CDI specialist at a family practice and internal medicine clinic revealed 1,353 coding errors on physician-coded claims for outpatient office visits. Tammy Trombley, RHIT, CDIP, CCDS , reviews findings from this 2017 audit and discusses implications for risk-adjustment coding.
The American Medical Association recently released the 2019 CPT code set, which includes 335 code changes, primarily for skin biopsies, fine needle aspirations, and central nervous system assessments. All changes take effect January 1.