Social issues often get left out of the conversation when providers, caregivers, and patients are busy, stressed, and focused on the immediate problem that occasioned a visit or admission; however, Nicole Nodal-Rodriguez, MSN, RN, CCDS , considers how having SDOH carried through the record can have a trickledown effect on treatment plans, identification of health disparities, and community services.
Accurate coding of hepatitis C scenarios relies heavily on recognizing and interpreting key details within clinical documentation, paying close attention specifically to the type of hepatitis, the acuity of the condition, the current status of the disease, and any associated complications or comorbidities. Note : To access this free article, make sure you first register if you do not have a paid subscription.
With its enhanced specificity and comprehensive structure, ICD-11 offers a more detailed and accurate framework for documenting cancer diagnoses. Karla VonEschen, MS, CCDS-O, CPC, CPMA , explores how precise documentation and the coder’s ability to capture all the diagnosis codes to fully describe the condition will be crucial for healthcare organizations.
The National Institutes of Health recently released a study that found an artificial intelligence screening tool was as effective as healthcare providers in identifying hospitalized adults at risk for opioid use disorder and referring them to inpatient addiction specialists. The tool also has the potential to reduce readmissions.
Jenny Esper, RHIA, CDIP, CCS, CCDS , and Lizabeth Volansky, BSN, RN, CCDS, RHIA, CDIP, CCS , explore the topic of including references or links to definitions within query notes and how such a practice can enhance documentation and coding.
Review a study based on ICD-10-CM data from the National Vital Statistics System that shows life expectancy for the United States population increased to 78.4 years in 2023 while the mortality rate decreased by 6.0% to 750.5 deaths per 100,000 of the standard population in 2023. Also determined were leading causes of death.
Psychosis often emerges or is managed in outpatient mental health settings, but it can be coded during inpatient hospital stays due to the acute nature of the condition when it reaches a crisis point. To ensure that this mental health diagnosis receives the same diligence as medical and surgical diagnoses, Nancy Reading, RN, BS, CPC, CPC-P, CPC-I , provides coders with guidance on finding the right codes and resolving documentation conundrums.
The ICD-10-CM classifies deep vein thrombosis with a high degree of specificity based on severity, affected extremity, vein location, and laterality, but without detailed clinical documentation or consistent terminology use, coders may need to query providers often for clarification in order to assign the right code.
