Amy Sanderson, MD, says that the term “dysphagia” has many synonyms used by providers in medical documentation. However, not all of these symptoms are able to describe the diagnosis with enough specificity so that it can be translated into its corresponding code assignment.
In many cases, knowing when to query is simple, but the more challenging cases contain clues that require additional interpretation. Drew Siegel, MD, CCDS, takes a look at a few of the more interesting and often undocumented diagnoses, including respiratory failure and acute kidney injury, and points out the diagnostic clues to form a compliant query.
Emergency departments (ED) at designated trauma centers encounter some of the most complex patients—and with them, a complicated documentation web that’s difficult for even the most experienced CDI specialists and coders to untangle.
When building a successful proactive clinical documentation approach, the effort of setting up communication dynamics is essential and should certainly be a priority.
Just like their inpatient acute care counterparts, inpatient psychiatric facilities use ICD-10-CM codes, but their payment structure, documentation requirements, prevalent clinical conditions, and additional documentation requirements needing capture are vastly different.
Allen Frady, RN-BSN, CCDS, CCS, CRC, reviews proposed changes applicable to coding and CDI teams within the fiscal year (FY) 2019 IPPS proposed rule including HIV disease, ARDS, and CC/MCC changes.
Though larger facilities may have had CDI programs for years that work in conjunction with the inpatient coders—some for over a decade—others are only starting now.
Allen Frady, RN-BSN, CCDS, CCS, CRC, reviews various guidance related to clinical validation to help coders and CDI teams better navigate the complex topic.
When planning to implement a coding auditing program, the type of reviews, focus areas, and review frequency must all be taken into consideration. Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS , details how to conduct an effective coding audit and ensure compliance with documentation requirements.
