Lynelle A. Clausen, RN, BSN, writes about the struggles she faces as a CDI specialist when dealing with vague documentation, lack of criteria, and the reporting of malnutrition.
A report released by the American Hospital Association and Manatt Health found that facilities spend approximately $39 million annually to comply with 629 requirements across nine regulatory domains.
Q: I have a question regarding unilateral weakness from a previous stroke. The patient has ongoing weakness in both right arm and leg post cerebrovascular accident (CVA) and associated ataxia post CVA in 2013. What is the accurate code assignment?
While a facility’s case–mix index is an important metric to measure, program managers and directors warn that metrics mean different things to different stakeholders and that CDI programs need to work diligently to present their data within the context of a host of other important measures.
Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, writes about the Office of the Inspector General’s (OIG) recent audit findings regarding the ICD-9-CM diagnosis code for kwashiorkor, and discusses what coders can do to stay compliant when coding guidance is lacking. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Victoria M. Hernandez, RHIA, CDIP, CCS, CCS-P , AHIMA-approved ICD-10-CM/PCS trainer, and Debi Primeau, RHIA, FAHIMA , highlight several areas that illustrate the increasing importance of code specificity to ensure accurate reporting and appropriate reimbursement.
James S. Kennedy, MD, CCS, CCDS, CDIP, interprets the various guidance given in Coding Clinic , Fourth Quarter 2017, including pre-bill audits and denials based on clinical criteria, and chronic obstructive pulmonary disease with exacerbated asthma.
Q: What would be the ideal way to code a case where a patient has ongoing encephalopathy after a subdural hematoma multiple years ago? I keep seeing documentation as a brain injury with ongoing encephalopathy, but is there a way to improve on this?
Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , writes that understanding the epidemiology of HIV, its manifestations, and its stages are important when reviewing the medical record for ICD-10-CM coding, and interpreting provider documentation and understanding the coding guidelines are of the upmost importance for proper sequencing.
Jocelyn E. Murray, RN, CCDS, reviews the similarities and differences between CDI audits and coding compliance audits and says it’s our collective responsibility to provide the insight that defines the two specialties and the critical efforts both bring to the table.
