Q: We recently had attending physicians send back queries with responses by the physician assistant (PA) or nurse practitioner (NP) who documented for them. Is it acceptable for a PA or NP to answer queries after the patient is discharged?
Sherry Corsello, RHIT, CPC, writes about how to ensure consistency and reliability of records in ICD-10 and what providers can do with the more accurate data the code set will give them.
Extensive changes in ICD-10-CM terminology and codes for cardiovascular diseases often frustrate coders, says Cindy Basham, MHA, MSCCS, BSN, CCS, CPC . She provides an overview of the changes and notes what must be documented so coders can select the appropriate code.
Linda Renee Brown, RN, MA, CCDS, CCS, CDIP, writes about the importance of tracking venous thromboembolism at hospitals and how to ensure physician documentation includes the correct level of detail to capture it.
Can you begin to imagine how complex a piece of great literature would be if we had to include complete documentation of each medical incident? Or have to stop every time we have to develop physician...
We’re all thinking about documentation specificity needs in ICD-10-CM/PCS as we prepare of the October 1, 2014 compliance deadline. Increased communication between physicians and coders is paramount...
Can you code ICD-10 from the documentation your physicians currently provide? Look at several records for each of your physicians and ask yourself whether you could assign codes in ICD-10 based on...
Our friends at the Association of Clinical Documentation Improvement Specialists (ACDIS) and 1,400 or so of their closest friends have descended on San Antonio for their annual conference. Things did...
Coding depends on clear and accurate documentation, especially with the added specificity available in ICD-10-CM. Andrea Clark-Rubinowitz, RHIA, CCS, CPCH , highlights tactics for improving provider documentationahead of implementation.
Emergency Departments (EDs) see a wide range of illnesses and injuries, from minor to major, which may require critical care. Lois E. Mazza, CPC, details how critical care is defined, what elements providers must document, and under what circumstances critical care can be coded for ED patients.
