CDI

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.

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.

Experts say ICD-10-PCS may be more challenging for coders coding procedures than for ­physicians trying to document information.

CDI specialists shouldn't focus on reimbursement, yet the reality is that improved documentation often does lead to higher payments for the hospital.

Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician documentation to accommodate the new code set was a top concern for the healthcare industry.

Everyone knows that CCs and MCCs are under scrutiny these days. ­However, that doesn't mean hospitals should err on the side of ­caution when reporting these conditions. William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Fla., provides several tips that coders can employ to look for clinical evidence in the ­record before querying for these targeted conditions.