CDI specialists must be able to apply both clinical and coding knowledge in order to discern relevant clinical conditions, and they must be able to analyze the quality of provider documentation and identify any gaps or inconsistencies in information between the health record and the associated data.
Acute kidney injury (AKI) is a sudden and temporary loss of kidney function, while acute tubular necrosis (ATN) is a kidney injury characterized by acute tubular cell injury and dysfunction.
The CMS hierarchical condition category (CMS-HCC) methodology recognizes specific combinations of diseases as well as the effect of disease processes as related to different settings of care. These metrics are important to understand in order to ensure proper reimbursement, even within the inpatient coding and CDI sector.
ICD-10-CM codes for traumatic fractures specify the type of bone injury, affected area of the body, and in some cases, the degree of soft tissue damage. Review orthopedic terminology and ICD-10-CM documentation requirements for traumatic fractures to resolve the coding challenges.
ACDIS and AHIMA recently released a position paper detailing CDI technology standards. The paper covers information on the variety of technology solutions currently available, strategies to assess compliance with CDI and coding practice guidelines, and methods for creating synergy between CDI and coding departments and novel technology solutions.
We would fail to see ourselves completely if we didn’t consider external views as well, so for this article, we’ll be looking at CDI-focused works from the medical literature.
Coding for conditions complicating pregnancy and delivery can be challenging, given the number of factors that influence maternal and fetal health. This article details ICD-10-CM coding for cervical incompetence, in vitro fertilization (IVF), and postpartum care complications.
Coding and CDI programs can take many approaches to manage denials, whether they focus on physician documentation education, have a team member dedicated to writing appeals, or anything in between.
