Rachelle Musselman, BSN, RN; Jorde Spitler, BSN, RN; Daniel Lantis, BSN, RN; Joseph E. Ross, MD; and Thomas A. Taghon, DO, MHA, review their experience with implementing pediatric heart failure criteria at Dayton Children’s Hospital.
Julian Everett, RN, BSN, CDIP, writes that early recognition of sepsis in pediatric patients, along with accurate reporting, is vital to the future of healthcare. With the goal of improving patient outcomes through documentation, Everett outlines her experience in providing documentation education to physicians.
While “myocardial ischemia” is a familiar term to CDI professionals and inpatient coders, the term “myocardial injury” does not share the same widespread recognition. In this article, Adriane Martin, DO, FACOS, CCDS , deciphers the clinical criteria and reporting guidelines for capturing myocardial injuries and demand ischemia.
In part one of this two-part series, Sharme Brodie, RN, CCDS , reviews the recent guidance from Coding Clinic , Second Quarter 2019, including cardiac conditions, transplants, and more.
Sarah Nehring, CCS, CCDS, says that the last thing a query writer wants is to provoke a defensive response, but in the current healthcare environment, CDI specialists, clinical, and inpatient coding staff need to think defensively. In this article, Nehring outlines five items to remember when it comes to defendable queries, documentation, and coding.
Cathy Farraher, RN, BSN, MBA, CCM, CCDS, writes that CDI professionals can work to reduce the incidence of physician query fatigue and gives recommendations to help improve provider response rate while reducing query frustration.
Tamara Hicks, RN, BSN, MHA, CCS, CCS, ACM-RN, CCDS-O , explains how her organization implemented a CDI career ladder and why it’s an important step for hospitals looking to expand their coding and CDI departments.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS , explains why physicians may feel that coding and CDI professionals are asking too much and offers potential solutions to ease workplace tensions.
Keeping up with commercial payer requirements can stump any revenue integrity department, and commercial payer audits can be an especially tough puzzle to solve. Review advice from experts on improving internal processes for dealing with commercial audits.
Adriane Martin, DO, FACOS, CCDS , writes about how to accurately capture and report social determinants of health to improve patient outcomes and decrease costs. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Patients who use oxygen at home for a primary respiratory condition typically present with some degree of respiratory failure. Howard Rodenberg, MD, MPH, CCDS , describes common documentation issues related to oxygen requirements for the diagnosis of acute respiratory failure.
Sarah Nehring, CCS, CCDS, says that from the inpatient coding and CDI perspective, sepsis can be one of the trickiest diagnoses. In this article, she reviews 10 things coders wish physicians knew about sepsis documentation and coding.
Although computer-assisted coding and natural language processing software has improved many aspects of daily CDI work, the technology requires ongoing oversight to ensure efficacy and accuracy. Therefore, CDI professionals, and even inpatient coders, need to be aware of the software’s potential pitfalls within the CDI department and develop tactics to overcome them.
Kay Piper, RHIA, CDIP, CCS, details the process of submitting ICD-10-CM codes to the ICD-10 Coordination and Maintenance Committee meeting by sharing the experience a medical coding educator and a CDI physician adviser had when submitting a proposal for the March 2018 meeting.
Cheryl Manchenton, RN, explains CMS’ Hospital-Acquired Condition Reduction Program (HACRP) and says inpatient coding professionals can play a significant role in HACRP success by understanding the basis for hospital-acquired condition scores and ensuring that documentation and coding accurately and fully captures patient conditions and complications.
Joe Rivet, JD, CCS-P, CPC, CEMC, CHC, CCEP, CHRC, CHPC, CICA, CPMA, CAC, CACO, writes that proper reporting and documentation of chronic obstructive pulmonary disease (COPD) will help ensure accurate MS-DRG assignment and strengthen cases during inpatient audits. 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, reviews the clinical validation of acute congestive heart failure (CHF) exacerbation and shares his hospital’s coding and documentation strategy to help in appeal battles.
Not many clinical conditions cause more consternation for inpatient coders and CDI specialists than acute and chronic respiratory failure. In this article, William E. Haik, MD, FCCP, CDIP, details acute and chronic respiratory failure and the critical elements in the health record that validate their reporting.
The benefits outweigh the difficulties when it comes to retrospective reviews. How do you get started with this new venture? Like many aspects of CDI, there are many ways to approach the problem. This article details these approaches, including how to enhance coder and CDI collaboration for these reviews.
CDI professionals can improve documentation and data scores via a mortality review process. This article discusses the various types of mortality reviews and publicly reported data and gives tips on how to implement a successful mortality review process.
