The primary purpose of CDI work is to review medical records to increase the accuracy and specificity of provider documentation. Review the primary responsibilities of a CDI specialist including documentation review, querying, and physician education.
Physician documentation of heart failure must specify the type and severity of the illness to apply the most accurate code. Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM , breaks down clinical documentation and ICD-10-CM coding for four types of heart failure.
Patients are often admitted for acute conditions and experience additional issues affecting their care and treatment plan during the encounter. Ashayla Stephens, MHA, RHIA, CCS , and Audrey Howard, RHIA , describe the process of validating multiple diagnoses documented within the health record. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: Our coding team has been having trouble understanding how to correctly report diabetes mellitus (DM) “with” other conditions in ICD-10-CM. Can you provide some guidance on this issue?
The Office of the Inspector General (OIG) recently announced it will conduct statewide reviews to determine whether hospitals complied with Medicaid billing requirements when assigning severe malnutrition diagnosis codes to inpatient hospital claims.
One of the biggest components of a leader’s role is to track, trend, and report on the department’s performance. Learn strategies for balancing priorities and time constraints and presenting key performance indicators to leadership.
Due to the complex nature of sepsis, some cases require querying the provider prior to assigning ICD-10-CM/PCS codes. Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM , breaks down inpatient coding and querying for sepsis.
Computer-assisted coding (CAC) technology analyzes healthcare documentation and selects codes based on specific phrases and terms. Review the pros and cons of using this software to perform inpatient coding and billing functions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
One of the biggest components of a leader’s role is to track, trend, and report on the department’s performance. Key performance indicators can range in complexity depending on the needs of the organization, but all are imperative for proving the success of a CDI or coding program.
Inpatient coders know that clinical indicators for certain conditions frequently require greater completeness or specificity in ICD-10-CM for which a concurrent or retrospective query is often required. This article will review clinical indicators and query opportunities for common respiratory conditions such as pneumonia, respiratory failure, and asthma.
