In an ideal world, all coders and CDI specialists would get along well and work together with minimal conflict. No one is going to agree all of the time, nor should they. A healthy, respectful dialogue can lead to a better understanding of the patient's clinical condition and result in more accurately coded records.
Coding professionals may inappropriately assign codes from parts of the medical record where the doctors, early in the workup of a complex patient, were describing differential diagnoses in their evaluation of the patient. Robert S. Gold, MD, discusses whether coders should report every diagnosis mentioned in a patient’s chart.
Acute kidney injury (AKI) is an abrupt decrease in kidney function that includes—but is not limited to—acute renal failure. Garry L. Huff, MD, CCS, CCDS , and Brandy Kline, RHIA, CCS, CCS-P, CCDS , explain the clinical indicators of AKI and offers tips for composing queries.
Hospital value-based purchasing (HVBP). It's the latest buzz phrase in the healthcare industry, and it's something in which all insurers are interested.
Coders are constantly analyzing documentation for clues and details that may indicate the need for a physician query. For example, coders should watch for clinical evidence that points to a condition that the physician may not have explicitly documented. Coders also need to be wary of reporting conditions without accounting for context or other clinical indicators in the documentation. William E. Haik, MD, CDIP, explains how this can lead to inappropriate reporting of an MCC, for example, that the overall clinical picture does not support.
