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.
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.
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.
CMS recently issued a bulletin highlighting new Medicare documentation guidelines and providing additional resources for documentation compliance. Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS , outlines the key takeaways from this latest guidance and emphasizes how health information, CDI, and coding teams play a role in compliant documentation.
Coders play a crucial role in addressing clinical and coding denials, but they are far from alone in this effort. All HIM professionals are working together to create and implement comprehensive strategies that effectively reduce denials, fostering a unified approach to overcoming these challenges.
ICD-10-CM official guidelines once stated that if there is conflicting documentation in the health record, the documentation of the attending physician supersedes that of any other provider. With that rule now gone, Cheryl Ericson, RN, MS, CCDS, CDIP , helps clarify who should be determining diagnoses.
One of the most frequent causes of hospital-acquired AKI is acute tubular necrosis (ATN). Improving documentation and coding practices for ATN involves not only recognizing the condition but also realizing the impact of coding ATN versus AKI, addressing common misconceptions in the HIM field, and fostering collaboration among CDI specialists, coding professionals, and providers. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Leveraging tools like clinical decision support (CDS) systems and physician queries can improve patient care and ensure documentation integrity. Yet medical coders need to ensure they use automated guidance without overstepping into clinical decision-making, maintaining the integrity of both documentation and coding while avoiding potential misinterpretations or misrepresentations of a patient’s condition.
The spectrum of myocardial injury, ischemia, and infarction represents a critical area in cardiology, which Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , explores in detail, integrating information from current clinical guidelines, diagnostic standards, and management strategies.
Anemia is a complex condition to manage clinically and document accurately, yet proper diagnosis, documentation, and coding are critical for ensuring appropriate patient care and reimbursement. Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , explores the clinical aspects of anemia, including its definitions, types, causes, and management, while addressing the challenges in clinical documentation and coding.
Because multiple organ disfunction syndrome does not have a specific ICD-10-CM code, coders face the challenge of capturing the full complexity of the condition. Nevertheless, understanding the various organ systems involved and recognizing the specific dysfunctions can help coders accurately report the condition. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
If denials are not going anywhere anytime soon, increasing at an alarming rate, and causing organizations to close, how do hospitals ameliorate this issue? Hospitals, including coders, can work to stem it by understanding the different types of denials, the problems they pose, and the tactics required to fight them.
Because substance use, abuse, and dependence are critical areas within healthcare that impact CDI and coding, Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , provides readers with an in-depth analysis of these conditions and emphasizes their clinical, diagnostic, and coding implications.
An upcoming audit reviewing Medicare inpatient hospital billing for sepsis underscores the critical importance of accurate coding and clinical validation. With guidance from Leigh Poland, RHIA, CCS, CDIP, CIC , coders can help prevent costly coding errors, reduce the risk of audits, and ensure hospitals are appropriately reimbursed for the care they provide. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS , invites a deeper understanding for diagnosing and documenting acute renal failure and any other related diagnoses—before exploring the plethora of denial strategies medical staff may face. Not to worry as there are opportunities for successful appeals!
Acute respiratory distress syndrome presents a significant clinical challenge due to its rapid onset, high mortality rate, and complex management. Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , delves into the comprehensive aspects of ARDS to show how coders, alongside healthcare providers and CDI specialists, play an essential role in reporting the complete picture of the condition.
With guidance from three certified medical professionals, CDI specialists and coders can learn how to fight against the overwhelming tide of clinical validation denials by promoting strong documentation, capturing clinical pictures with appropriate codes, and justifying treatment plans.
Review a recent OIG audit which found that Medicare payments for inpatient claims assigned with MS-DRGs 207 and 870 did not fully comply with Medicare requirements, resulting in $79.4 million being improperly paid to hospitals.
