Q: What are some of the common documentation pitfalls or missteps related to pediatric malnutrition? And what can CDI specialists do to address them proactively?
Shelley C. Safian, PhD, MAOM/HSM/HI, RHIA , explains ways administration can establish an organizational culture of legal and ethical responsibilities to maintain compliance and honor patients and staff.
Teresa Brown, RN, CCDS, CDIP, CCS, explores the significance of the Elixhauser Comorbidity Index in enhancing our understanding of patient health profiles and supporting informed decision-making across various facets of healthcare delivery.
Protect your office/outpatient E/M claims from front-end denials and post-payment recoupments with the freshest information from Medicare administrative contractors (MAC).
Organizations need to decide how to manage the clinical validation conundrum effectively and consistently. Trey La Charité, MD, FACP, SFHM, CCS, CCDS, explores one denial prevention tactic that has proved most effective for his organization.
Our experts answer questions about coding for controlled puerperium diabetes and endoscopic procedures as well as provide suggestions for referring to prior encounter information in queries.
It can be especially challenging to thoroughly document rendered services in the emergency department due to the unique needs of the setting. Hamilton Lempert, MD, CEDC, reviews several areas of critical care coding that may trip up clinicians and coders.
Q: A physician documented metabolic encephalopathy on a postoperative patient who was sedated on a vent, but because there were not documented responses while on the vent, I was unable to clinically validate the encephalopathy while the patient was sedated on the vent. How would a coder query this diagnosis for validity?
