Physician documentation drives quality measures, but physicians often don't understand how the quality of their documenation relates to their quality of care.
The April 1 confirmation of the delay in implementing the ICD-10 code set until at least October 1, 2015, certainly took the wind out of many healthcare organizations' sails.
At the time of this publication, the Protecting Access to Medicare Act of 2014 bill was recently passed. The status quo regarding physician reimbursement from Medicare has been maintained. So what? That system has been broken for 20 years. ICD-10 will be postponed for provider billing for another year. So what? Life will go on as it has for the past 36 years with ICD-9-CM. In other words, nothing has changed. We're good for another year. Pressure's off! ...Right?
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.
