Emmel Golden, MD, FCCP, CCDS , reviews three recent studies detailing sepsis trends in the U.S. and writes that now is a great time to shed light on how important complete, precise documentation and coding are to understanding the sepsis health challenges we face as a country.
Q: What are the benefits to having coders review charts for appropriate capture of CCs and MCCs, and how can our coding team get started in this process?
In this article, Laura Evans, CPC, reviews 2021 E/M coding for outpatient encounters based on provider documentation of medical decision-making (MDM). She breaks down the four levels of problems addressed and describes the types of conditions that would fall into each category.
Q: When might it be appropriate to report computer-aided mapping of the cervix uteri using 2021 CPT add-on code 57465 (computer-aided mapping of cervix uteri during colposcopy, including optical dynamic spectral imaging and algorithmic quantification of the acetowhitening effect)?
Hospital coding for pregnancy-related services requires a detailed understanding of the CPT® global obstetric (OB) package and ICD-10-CM coding guidelines for maternal care management. This article details hospital coding for pregnancy and delivery complications and procedures used to treat them. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
One concern CDI professionals and inpatient coders say they struggle with is physician engagement and education. Without an engaged physician staff, CDI and coding efforts will languish with unanswered queries and subpar documentation practices.
The HIM department plays a critical role in the revenue cycle, but it’s often placed in a reactive position, limiting its effectiveness. Learn how to improve operations by enhancing the HIM department’s involvement across the revenue cycle.
