Jorde Spitler, RN, CDI manager at Dayton Children’s Hospital, describes key considerations for documentation review, querying, and ICD-10-CM coding in a pediatric acute care setting.
Determine whether your facility needs to change E/M documentation habits and capture different details based on the revisions made by CMS to observation and inpatient reporting in the 2023 OPPS final rule.
Q: A 4-year-old managing lissencephaly, hypotonia, and dysphagia with aspiration of secretions presents with fever and tachypnea. A chest x-ray shows right lower lobe infiltrates. Would it be appropriate to query the provider to confirm a diagnosis of pneumonia?
As healthcare systems look to replicate successful CDI programs outside of large complex community or academic health centers, there are unique considerations for rural settings.
Postoperative mortality rates among Medicare beneficiaries are associated the characteristics of patients’ neighborhoods and the hospitals where they received treatment, according to a study published in JAMA Network Open in January.
Q: What are the differences between remote therapeutic monitoring and remote physiologic monitoring and what details should we look for in documentation to report these services with CPT codes?
This article outlines kidney anatomy, explains percutaneous nephrolithotomy and pyelolithotomy procedures, highlights relevant CPT guidance, and includes insight from experts. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Tonya Moton, RHIA, CCS, defines social determinants of health coding, explains the challenges of reporting these factors, and outlines how coders and providers can work together to create a positive impact in at-risk communities.
The 2023 Medicare Physician Fee Schedule (MPFS) final rule finalized major documentation and coding changes. This article summarizes new guidance for reporting E/M and telehealth services and a significant cut to physician payments.
CMS recently published an FAQ document on the use of drug waste modifiers. The resource addresses how the modifiers affect Medicare policy, to which products they can be appended, billing concerns, and more.
