In part one of this two-part series, Allen Frady, RN, BSN, CCS, CRC, CCDS, gives tips to CDI and coding teams on how to help improve healthcare quality scores by reviewing CMS star rating calculations, department challenges, physician education, and more.
It’s important for inpatient coders to frequently review hospital-acquired conditions (HAC) and present on admission (POA) indicators and the rules governing their assignment in order to ensure proper reimbursement. Part one of a two-part series will review POA indicators in particular.
Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC, MSHIM, RHIA, says with recent audit activity and the Office of Inspector General’s continued scrutiny of malnutrition diagnoses, it’s important to dig into the coding and documentation requirements for this tricky diagnosis, particularly in the case of COVID-19 patients.
In this article, Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC, RHIA, says inpatient coding professionals need to look for signs and symptoms supportive of sepsis in order to report the most accurate codes, which is why staying up to date on the ever-changing clinical criteria for sepsis is so important.
Howard Rodenberg, MD, MPH, CCDS , writes that ensuring the social determinants of health are appropriately documented within the medical record allows CDI and coding teams to capture the hard data needed to demonstrate the interactions among race, gender, ethnicity, and other key socioeconomic indicators with healthcare costs, utilization, and outcomes.
Inpatient coding professionals must have a clinical understanding of COVID-19 and the disease process in order to accurately sequence diagnoses, code etiology and manifestations, and assign present on admission (POA) indicators. In this article, Audrey Howard, RHIA , and Susan Belley, RHIA, CPHQ, focus on coding issues related to POA indicators for the hospitalized, inpatient COVID-19 population.
In a year of unprecedented disruption and uncertainty, coding productivity managed to hold steady, according to the results of HCPro’s 2020 Coding Productivity Survey. Review the survey results, which provide data on facility coding productivity, accuracy benchmarks, and more.
Both sepsis and malnutrition remain top denied diagnoses, and there is little sign of those denial rates slowing. This article is part two of a two-part series that zeros in on clinical validation and denial prevention for these two diagnoses.
Both sepsis and malnutrition remain top denied diagnoses, and there is little sign of those denial rates slowing. Part one of this two-part series will take a closer look at malnutrition and sepsis criteria challenges, while part two will zero in on clinical validation and denial prevention for these two diagnoses.
Review clinical indicators for various types of encephalopathies including toxic or metabolic encephalopathy, hypertensive encephalopathy, and hepatic encephalopathy. Frequently reviewing clinical indicators for these complicated diagnoses will ensure both proper coding and reimbursement.
Sydni Johnson, RN, BSN, CCDS , and Denice Piwowar, BSN, RN, CCDS , detail some basics of clinical validation and how to request supporting indicators of a documented diagnosis without questioning the provider’s judgment.
Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, writes that the better the CDI policies and procedures, the better CDI and inpatient coding departments can work efficiently together to achieve proper documentation, coding, and reimbursement.
Up to now, public health data collection has been mainly focused on adult COVID-19 patients, but we are beginning to see data indicating that COVID-19 is impacting children’s health as well. With more of the spotlight on pediatric COVID-19 diagnoses, it’s important to ensure proper documentation to help improve data collection.
According to Johns Hopkins Medicine, approximately 30% of patients with the novel coronavirus (COVID-19) have acute kidney injury (AKI). Because of this, Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC, details COVID-19-related AKI to ensure accurate documentation and appropriate queries.
Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM, explains the definition of acute ischemic syndrome and the clinical indicators that make a difference when reviewing a medical record. In part two of this two-part series, Kuqi takes a look at myocardial infarctions (MI), treatments for MIs, and clinical documentation concepts.
Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM, explains the definition of acute ischemic syndrome and the clinical indicators that make a difference when reviewing a medical record. In part one of this two-part series, Kuqi takes a look at the myocardial anatomy, stable/unstable angina, and Prinzmetal's angina.
Julian Everett, RN, BSN, CDIP, reviews ICD-10-CM reporting and clinical criteria for pneumonia and its causative agents and associated comorbidities. Everett also details documentation recommendations for providers to ensure inpatient coders can report this disease with the utmost accuracy.
