Coders and clinicians seem to speak different languages. CDI specialists often serve as the translators between clinicians and coders, so it's important that all three groups work together.
The UHDDS defines principal diagnosis as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. That means the principal diagnosis is not always the condition that brought the patient into the hospital.
Coders live in a very difficult world. They want to do what is best for their organization based on the documentation they have, but sometimes the documentation is incomplete. The patient’s clinical picture can help coders decide when a condition rises to the level of a CC.
All pressure ulcers are wounds, but not all wounds are pressure ulcers. A wound is an injury to living tissue caused by a cut, blow, or other external or internal factor. Wounds usually break or cut the skin.
Does the patient really have sepsis? Experts say coders often struggle with this question because physicians don't sufficiently document clinical indicators.
When Paul Belton, RHIA, MBA, JD, LLM, speaks about the culture at Sharp HealthCare in San Diego, you can hear the pride and enthusiasm swelling in his voice. Having served as the vice president of corporate compliance for the past 15 years, Belton has led the ongoing effort to ensure that all employees "do the right thing" at all times.
Charging for inpatient ancillary procedures and supplies has always been confusing. "CMS provides very little guidance ... Its theory is that it's up to the provider to figure it out," says Kimberly Anderwood Hoy, JC, CPC, director of Medicare and compliance at HCPro, Inc., in Danvers, Mass.
More than 8% of the population in the United States (i.e., 25.8 million children and adults) has some form of diabetes, according to the American Diabetes Association. In 2007, diabetes was listed as the underlying cause on 71,382 death certificates. It was a contributing factor on an additional 160,022 death certificates.