Chronic kidney disease (CKD) is a manifestation of many different chronic disease processes, including diabetes, hypertension, and immune complex diseases. Garry L. Huff, MD, CCS, CCDS , and William E. Haik, MD, FCCP, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, explain the clinical indicators of CKD as well as coding and documentation problem areas.
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.
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.
