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.
ICD-10-CM/PCS incorporates laterality, acuity, anatomical specificity, and a slew of additional combination and complication codes. Who will submit queries when this information is missing in a medical record? Will coders or CDI specialists take on this role? Perhaps it might be a combination of the two.
Do not view the proposed rule extending the ICD-10 implementation date from October 1, 2013, to October 1, 2014, as a year-long break from ICD-10 preparations. Rather, focus on using the additional time allotted to your advantage. This includes conducting documentation and coding assessments to gauge ICD-10 readiness. Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, explains why—and how—facilities should start assessing the readiness of their coding staff and documentation procedures in relation to ICD-10 requirements and create strategies to manage any deficiencies.
The best way to decrease denials or increase overturn rates begins with a compliant concurrent review of documentation. Marilyn S. Palmer, DO, and Jonathan G. Wiik, MSHA, MBA, review common Recovery Audit targets and provide tips for successfully appealing denials.
Coding managers and their team members sometimes must approach physicians in person regarding documentation. Clarification may be necessary, or perhaps you will need to coax the physician to complete certain records without further delay.
How well could you code in ICD-10 using your current physician documentation? Do your physicians document the specificity and detail coders need to select the correct ICD-10-PCS code? Do your physicians document laterality, which coders will need for many ICD-10-CM codes?
The increasing complexity of the healthcare reimbursement system, quality initiatives, and the transition to ICD-10-CM/PCS put clinical documentation improvement programs in the spotlight . Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, discusses the importance of documentation improvement specialists.
