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.
CMS recently announced a new HCPCS Level II code for COVID-19 convalescent plasma administered in the outpatient setting, effective for claims submitted on or after December 28, 2021.
Under certain circumstances, a service or procedure may be partially reduced or eliminated at the discretion of the physician. Read up on the correct application of hospital modifiers -52, -73, and -74 for reduced and discontinued procedural services.
CMS recently released new HCPCS modifiers -FR, -FQ, -FS, and -FT for telehealth visits. Julia Kyles, CPC , breaks down reporting guidance for these new physician modifiers that took effect January 1.
To assign the most specific CPT codes for spinal procedures, coders need a solid understanding of spinal anatomy and surgical terminology. Review spinal anatomy and CPT coding for vertebral corpectomies, discectomies, laminectomies, and more. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Acute kidney injury (AKI) is a sudden and temporary loss of kidney function, while acute tubular necrosis (ATN) is a kidney injury characterized by acute tubular cell injury and dysfunction.
Organizations may opt to measure productivity using several methods, such as number of charts coded per day or per month, based on their needs, service lines, and other considerations. Some organizations use different productivity metrics for specific settings or account types.
Under certain circumstances, a service or procedure may be partially reduced or eliminated at the discretion of the physician. Read up on the correct application of hospital modifiers -52, -73, and -74 for reduced and discontinued procedural services.
Chapter 19 of ICD-10-CM includes codes for various types of injuries, poisonings, and other consequences of external causes. Review integumentary anatomy and ICD-10-CM coding for burns and superficial injuries.
Our experts answer questions about CPT coding for bunionectomies, 2022 CPT changes for reporting cataract removals, and ICD-10-CM coding for false labor.
The 2022 ICD-10-CM manual includes new codes for thrombotic microangiopathy (TMA)—a rare clinical syndrome defined by the presence of hemolytic anemia, organ dysfunction, and low platelets. Read up on TMA pathophysiology and diagnosis coding.
CDI specialists must be able to apply both clinical and coding knowledge in order to discern relevant clinical conditions, and they must be able to analyze the quality of provider documentation and identify any gaps or inconsistencies in information between the health record and the associated data.
The American Medical Association (AMA) recently announced three new CPT codes for administration of Pfizer’s COVID-19 vaccine in children 6 months to under 5 years old.
Q: What is the difference between anterior and posterior approaches to spinal surgery, and when might a physician use a combined (anterior and posterior) approach?
The 2022 ICD-10-CM manual includes new codes for thrombotic microangiopathy (TMA)—a rare clinical syndrome defined by the presence of hemolytic anemia, organ dysfunction, and low platelets. Read up on TMA pathophysiology and diagnosis coding.
State and federal prosecutors continue to extract sizable settlements from practices that allegedly submitted fraudulent claims for one type of service—urine drug tests (UDT). In this article, Julia Kyles, CPC , breaks down fraudulent coding and billing patterns for UDT services.
