The ICD-9-CM guidelines state that it's unusual for two or more diagnoses to meet the definition of principal diagnosis. However, coders know this isn't exactly true, as the scenario tends to occur frequently.
Coders can only use the documentation they have to code in ICD-9-CM and ICD-10-CM. Adelaide La Rosa, RN, BSN, CCDS, and Deborah Lantz, RHIA, discuss the importance of good documentation when coding for fractures and congestive heart failure in both systems.
Providers and coders seem to speak two different languages-clinical and coding. Providers already have issues parsing ICD-9-CM "coder speak," so how can you get them to understand ICD-10?
The clinical documentation specialist role is relatively new, but can be a great place for coders. Lois Mazza, CPC, reveals why coders should consider taking on this role.
Documentation and medical necessity continue to be scrutinized by payers and auditors. Debbie Mackaman, RHIA, CPCO, and Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, explain how complete, accurate documentation of the entire patient encounter justifies the physician’s decision to admit.
In the third part of our series on Patient Safety Indicator 90, we focus on inclusions, exclusions, and coding and documentation vulnerabilities for PSI 7.
Coders and clinicians seem to speak different languages. CDI specialists often serve as the translators between clinicians and coders, so it's important that all three groups work together. Cheryl Ericson, RN, MS, CCDS, CDIP , AHIMA-approved ICD-10-CM/PCS trainer, Darice M. Grzybowski, MA, RHIA, FAHIMA , Jonathan Elion, MD, Kathy DeVault, RHIA, CCS, CCS-P , and William E. Haik, MD, FCCP, CDIP , offer tips for determining when to query.
Coding, documentation, and diagnoses aren’t always clear-cut, which can challenge even experienced codes. Review the coding and documentation requirements for encephalopathy, stroke, and anemia.
Most hospitals have been overwhelmed by Recovery Auditor (RA) requests for documentation. So it's no surprise that the RAs themselves seem to be equally as burdened with the task of processing those records.
CDI specialists shouldn’t focus on reimbursement, yet the reality is that improved documentation often does lead to higher payments for the hospital. Darice Grzybowski, MA, RHIA, FAHIMA, and Jon Elion, MD, offer tips on how CDI programs can mitigate ethical quandaries and demonstrate best practice.
