ICD-10-CM official guidelines once stated that if there is conflicting documentation in the health record, the documentation of the attending physician supersedes that of any other provider. With that rule now gone, Cheryl Ericson, RN, MS, CCDS, CDIP , helps clarify who should be determining diagnoses.
Review a study based on ICD-10-CM data from the National Vital Statistics System that shows a decline in U.S. maternal mortality rates from 22.3 deaths per 100,000 live births in 2022 to a rate of 18.6 deaths in 2023.
One of the most frequent causes of hospital-acquired AKI is acute tubular necrosis (ATN). Improving documentation and coding practices for ATN involves not only recognizing the condition but also realizing the impact of coding ATN versus AKI, addressing common misconceptions in the HIM field, and fostering collaboration among CDI specialists, coding professionals, and providers. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Research of multiple countries on various continents and with varied complexity of healthcare environments reveals significant disparities in health outcomes and access to healthcare, and a staggering percentage of health outcomes are attributed to social determinants of health. Studying these countries shows differences in how socioeconomic issues are captured in documentation and coded using different patient classification systems, guidelines, and regulations.
