The first quarter of 2019 has ended. Do you know what that means? Unfortunately, it means that income taxes were due in April. But luckily for inpatient coders and CDI professionals, it also means that we have new Coding Clinic guidance to take our minds off our taxes.
A query is a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment for an individual encounter in any healthcare setting.
The beginning of the year is a time to go back to basics—or even, in some cases, to start over. Revisiting information on how to conduct a medical record review may, at first glance, feel like a basic or beginner topic. But medical record review is an important subject for all CDI professionals, and even coders, to consider.
Karen, a 67-year-old patient with a history of hypertension, diabetes, and tobacco use, presents to her primary care physician with complaints of pain in her right buttock and thigh when she walks from her house to her mailbox. She is then admitted as an inpatient for surgery.
Coders often wonder how to define realistic productivity benchmarks. Different facilities establish the responsibilities and expectations of their coding teams, so productivity standards are not uniform.Coders often wonder how to define realistic productivity benchmarks. Different facilities establish the responsibilities and expectations of their coding teams, so productivity standards are not uniform.
If we look at each element of a coding audit, we can see the benefits these coding reviews provide. Every healthcare organization and hospital should invest in routine, internal coding audits. The alternative is waiting until the payer conducts an audit, denies a claim, and incurs costs for the organization.
Consider the story of a patient—say, a pneumonia patient—whose treatment cost a lot of money. The hospital’s reimbursement for that care, however, was less than the cost of providing it. Now say someone looked at that case and how complex it was, and then saw that the reimbursement only paid for half the cost of caring for that patient. That’s how CDI was born.
In 2013 the “ Guidelines for Achieving a Compliant Query Practice ,” a collaboration between AHIMA and ACDIS, was published. It has served as the industry guideline for the establishment of best practices surrounding queries. Since that time this brief has been updated twice: once in 2016 and most recently in 2019 .