CDI

ICD-10-CM and ICD-10-PCS present different challenges, but both will require better documentation. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, Kathy DeVault, RHIA, CCS, CCS-P, Donielle Bailey , and Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, discuss some of the areas where coders will need more information to code in ICD-10.

The ideal approach to ICD-10-CM/PCS preparation is capitalizing on the synergistic partnership between clinical documentation improvement and coding professionals. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, discusses how organizations can use this dynamic to improve preparations for ICD-10.

Sometimes the physician's documentation is insufficient to represent what the patient actually has, meaning you need to go further.

Each new CMS fiscal year, MS-DRG weight and classification changes in the CMS IPPS final rule are closely scrutinized by coders and CDI specialists to identify any potential impact on documentation capture and code assignment processes.

Physicians often use the acronyms IBS (which should indicate irritable bowel syndrome) and IBD (which should indicate inflammatory bowel disease) interchangeably even though they represent completely different conditions with different treatment and prognoses.

A complication basically refers to an unexpected result, outcome, or event. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, Cheryl Ericson, MS, RN, CCDS, CDIP, and Trey La Charité, MD , detail when to report a complication and highlight the differences in complication coding between ICD-9-CM and ICD-10-CM.

Discover where your physician documentation falls short as you prepare for ICD-10.

Physicians often use different terms interchangeably when documenting sepsis. Robert Gold, MD , and Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, define the different terms and review when to query for additional clarification.

by Robert S. Gold, MD

How does medical necessity get “overlooked” on the physician side as well as the inpatient side? Case managers, utilization review staff, physician advisors, CDI specialists, and coders, each carry out specific duties and responsibilities when reviewing medical records. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, CCDS, examines contributing factors and takes a closer look at guidelines Trailblazer Health recently issued defining specific joint replacement (DRG 470) documentation that both hospitals and physicians should follow to support medical necessity.