Emergency departments at designated trauma centers encounter some of the most complex patients—and with them, a complicated documentation web that’s difficult to untangle, making trauma case review essential for hospitals.
Lynelle A. Clausen, RN, BSN, writes about the struggles she faces as a CDI specialist when dealing with vague documentation, lack of criteria, and the reporting of malnutrition.
Sharme Brodie, RN, CCDS, reviews the most recent Coding Clinic guidance, which touches on common coding conundrums from subjects such as clostridium difficile, diabetes with ketoacidosis, myocardial infarction, pulmonary hypertension, and more.
Mortality reviews pose a special challenge—not only does the CDI specialist need to know the ins and outs of severity of illness and risk of mortality, but the cases themselves are typically more complicated than an average hospital stay, making these essential reviews even more complex.
Crystal Stalter, CDIP, CCS-P, CPC, writes that with the release of the 2018 IPPS final rule, hospitals around the country are poring over it to see what impact the changes might bring to their case-mix index, quality initiatives, and overall reimbursement. In the midst of this are coders and CDI specialists who need to be kept abreast of these changes.
James S. Kennedy, MD, CCS, CDIP, writes that while you might have thought you’ve finally mastered coding compliance with DRGs and quality measures, now it is time to learn the compliance risks and opportunities with a new risk-adjustment method: Hierarchical Condition Categories.
Daniel E. Catalano, MD, FACOG, says that from the CDI perspective, the ability to communicate pediatric severity of illness is complicated by the fact that pediatricians have a lexicon that is not well captured in ICD-10-CM. This, he writes, is especially true for pediatric cardiology.
Beginning and sustaining a remote CDI program can be a challenge for even seasoned professionals. Traditionally, CDI specialists put in varying amounts of face-to-face time with the physicians. Ideally, that in-person interaction makes the physicians more open to CDI efforts. However, many remote CDI programs and individual specialists have found creative ways around this face-to-face time.
Sharme Brodie, RN, CCDS, reviews 2017 First and Second Quarter Coding Clinic advice, which includes sequencing chronic obstructive pulmonary disease with other respiratory diagnoses and body mass index reporting instructions.
Crystal R. Stalter, CPC, CCS-P, CDIP, writes about how fully specified documentation is the key to quality care, compliance, and eventual reimbursement, and how documentation software can help to streamline these processes.
The advent of the electronic record changed (EHR) how clinical documentation improvement specialists work with providers and coders. As more healthcare organizations take on the arduous process of implementing an EHR, new challenges and considerations arise.
Shannon Newell, RHIA, CCS, explains that pneumonia discharges impact hospital payments under the Hospital Value-Based Purchasing Program, as well as the Hospital Readmission Reduction Program, and conveys what CDI teams can do to help.
Trey La Charité, MD, FACP, CCDS , notes that getting a handle on a facilities’ case-mix index (CMI) fluctuations can be difficult, and shares insights to how CDI teams can handle these CMI difficulties.
After a year full of numerous coding changes, Laurie L. Prescott, RN, MSN, CCDS, CDIP , takes a closer look at 12 new guidelines that will affect CDI and helps coders better understand these recommendations.
Shannon Newell, RHIA, CCS, discusses a refined version of the Patient Safety Indicator (PSI) 90 composite by the Agency for Healthcare Research and Quality, and how it has a significant impact on what discharges are included in PSI 15. Note: To access this free article, make sure you first register for the free content if you do not have a paid subscription.
Trey La Charité, MD , writes about how he feels the days of merely maintaining compliance with published coding guidelines are gone, and suggests ways to protect a facility and appeal audits.
Shannon Newell, RHIA, CCS, writes about how certain hospitals will be required to participate in the Comprehensive Joint Replacement Model and a new orthopedic payment model called SHFFT if an August 2 proposed rule is finalized.
Laurie L. Prescott, MSN, RN, CCDS, CDIP , writes that as many CDI teams work to expand their risk adjustment programs, a melding of two skill sets, that of CDI specialists and coding professionals, are required to succeed.
Richard D. Pinson, MD, FACP, CCS , discusses the new Sepsis-3 definition and how the classification has been the subject of great controversy and consternation since its publication in The Journal of the American Medical Association.
