While focusing on documentation and coding, providers might not have considered the impact of MS-DRG shifts as a result ICD-10 implementation. Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, and Lori P. Jayne, RHIA, review how the new code set will affect several diagnoses.
Medical record audits provide opportunities to educate coders, physicians, and/or clinical documentation improvement specialists. Robert S. Gold, MD, offers tidbits about volume overload and heart failure from recent reviews he’s done.
With Recovery Auditor audits on hold, hospitals may have experienced a decrease in the number of audits that must be addressed. Cathie Wilde, RHIA, CCS, and Kim Carr, RHIT, CCS, CDIP, CCDS, explain why organizations still need to be able to justify code assignment.
PSI 7 evaluates the hospital’s risk-adjusted rate of central venous catheter-related bloodstream infections. Shannon Newell, RHIA, CCS, Steve Weichhand , and Sean Johnson explain inclusions, exclusions, and risk adjustment factors for this measure.
When providers use different definitions for the same disease, confusion and chaos result. Trey La Charité, MD , discusses how coding and clinical documentation improvement specialists can clear up the situation.
PSI 15 measures the hospital’s risk-adjusted rate of accidental punctures and lacerations. Shannon Newell, RHIA, CCS, Steve Weichhand , and Sean Johnson explain inclusions, exclusions, and risk adjustment factors for this measure.
Coders and clinical documentation specialists can use queries to improve physician documentation of a patient’s severity of illness and risk of mortality. Rhonda Peppers, RN, BS, CCDS, and Sara Baine, MSN-Ed, CCDS, walk through a case study to highlight query opportunities.
A hiatus from Recovery Auditor scrutiny may have allowed HIM professionals to focus on other issues, but Laura Legg, RHIT, CCS, explores why HIM departments need to gear up for Recovery Auditors’ return.
In the first part of a two-part series, Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, discusses the use of Z codes in ICD-10-CM.
Coders often talk about guidelines and coding conventions, but what about ethics? Robert S. Gold, MD , discusses the value of following ethical coding standards.
In part 2 of his series on medical necessity and coding, Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, examines medical necessity and the 2-midnight rule using a case study.
The Official ICD-9-CM Guidelines for Coding and Reporting talk about the perinatal and newborn period as being the first 28 days of life. Robert S. Gold, MD, explains when neonatal really is—and isn’t—neonatal.
Coders now incorporate consideration of medical necessity when coding for inpatient admissions. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI , explains the importance of understanding the concept of medical necessity as it relates to coding.
The complexity of coding rules and the quality of documentation in facilities sometimes make correct DRG assignment a daunting task. Laura Legg, RHIT, CCS, highlights current DRGs that are subject to Recovery Auditor scrutiny and provides tips for accurate DRG assignment.
Healthcare facilities are subjected to a myriad of auditorswho scrutinize everything from how many units of a drug were billed to whether or not a patient actually needed to be admitted to the hospital. Trey La Charité, MD , explains how to turn every denial into a learning experience.
Plenty of uncertainty surrounds the ICD-10 implementation delay, but healthcare organizations shouldn’t put the brakes on their plans. Cheryl Ericson, MS, RN, CCDS, CDIP , William E. Haik, MD, FCCP, CDIP , Monica Lenahan, CCS , Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and James S. Kennedy, MD, CCS, CDIP, offer thoughts on how to keep moving forward with ICD-10.
