It is evident with the complexity of this diagnosis (and the complexity of updated criteria) that even the most seasoned inpatient coder should review malnutrition coding guidelines and criteria frequently to ensure compliant reporting.
The brain is the most complex component of the central nervous system, consisting of approximately 100 billion neurons that communicate via an exponentially larger number of synapses. Individual areas of the brain have specialized functions that work in conjunction and regulate voluntary and involuntary body functions.
Hospitals should get their compliance strategies in top shape before the end of the year. CMS released the fiscal year (FY) 2019 IPPS final rule with significant reductions to reporting requirements for quality initiatives, updates to payment rates, changes to CC/MCC designations, and revisions to various MS-DRGs. CMS also finalized the requirement for hospitals to post their chargemaster online, effective January 1, 2019.
Data in CDI reports should demonstrate the depth of work performed as well as productivity elements. I want to share my experience of personalizing data fields in our CDI software to fully demonstrate our CDI team’s impact beyond moving the MS-DRG.
It’s true that most CDI specialists are not coders, and coding a record isn’t our specific focus. To complete our given mission, however, we must understand the process and the guidance related to code assignment. The focus of provider education is to assist in translating “coder speak” to “medical speak” and vice versa.
When pneumonia documentation is questioned, CDI specialists or coders should always query the provider. But reviewing the following clinical elements involving aspiration and pneumonias with your physician staff may help improve the documentation of complex pneumonias and avoid adverse determinations by external reviewers.
Like it or not, provider documentation is the foundation for everything done in medicine. Without it, nothing is accomplished. As healthcare reform progresses (and hospital reimbursement shrinks), the need for excellent provider documentation only increases.