In this article, Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC, MSHIM, RHIA , breaks down the various definitions and criteria for sepsis and reviews documentation and querying for this diagnosis through a case study.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS, writes that through updated heart failure definitions and clinical criteria, coders and CDI teams now have help to ensure that congestive heart failure is properly documented and denials are avoided.
Hospitals often put significant thought, time, and energy into hiring new team members, and while coding and CDI managers can have the best possible staff, if they don’t feel appreciated, the odds of them staying with the company long term are low.
Howard Rodenberg, MD, MPH, CCDS, writes that it only takes one or two inappropriate queries to a provider for the process to seem burdensome to them. To avoid this scenario, Rodenberg proposes three questions to consider once you’ve decided a query is in order.
In this article, we will take a closer look at clinical indicators for acute myocardial infarction, congestive heart failure, and arrythmias. Frequently reviewing clinical indicators for complicated diagnoses such as these will ensure both proper ICD-10-CM reporting and reimbursement.
You may wonder why an article about the coding of Hierarchical Condition Categories (HCCs) in the outpatient wound care setting is appearing in an inpatient periodical. When I first approached this topic, I focused on the outpatient wound care setting. But the more I thought about it, I realized this topic is pertinent for inpatient coders.
Documentation is an integral part of a patient’s healthcare encounter. Improper or imprecise documentation may create an inaccurate picture of what truly occurred during a patient’s hospital stay or outpatient visit. How do CDI and inpatient professionals capture the most accurate picture possible? The answer may lie in solving a more complex question: How do we encourage and expand critical thinking?
It’s not unusual for CDI and inpatient coding teams to cite physician education and engagement as one of their top struggles in the field. In this article, read how the CDI team at Avera Health System turned to their query data to craft a focused education program and meet their physicians on the same page.
Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC, MSHIM, RHIA, writes that CDI professionals and inpatient coders need to pay attention to the definitions and clinical indicators of acute kidney injury (AKI) to ensure proper ICD-10-CM reporting and reimbursement.
Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, reviews how critical thinking is important within the CDI and coding realm in order to enhance review accuracy and query rates and to help loosen reliance on technological tools such as encoders.
Dawn Valdez, RN, LNC, CDIP, CCDS, says that the clinical indicators used to validate sepsis can also have other possible etiologies that could be equally responsible for the clinical indicators that are present—these are known as competing diagnoses.
Howard Rodenberg, MD, MPH, CCDS, and Lynn Shay, CPHQ , say that making sense of varying COVID-19 case-mix index metrics is an important endeavor that will sometimes require a bit of DIY. In this article, they explain how they were able to unscramble their departments’ COVID-19 case-mix index data.
With most patient charts now housed in EHRs, technology has become a standard part of the healthcare industry. Growing technological adoption, however, means physicians spend an increasing amount of time on computers and using technology.
The kidneys filter waste and excess fluid from the blood. As kidneys fail, these wastes build up. The symptoms of chronic kidney disease (CKD) generally develop slowly and aren't specific to the disease. Often, there are no noticeable symptoms, and the condition is noted incidentally from a diagnostic testing, or the symptoms first appear once the disease course has reached significant impairment.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS, writes that organizations that aren’t reviewing all in-hospital mortality cases are missing some tremendous opportunities to improve reimbursement and documentation.
Pediatric record reviews require a different skill set than those in the traditional adult acute care space. Often, those reviewing these specialized charts are islands within their overall CDI or coding department, acting as the sole pediatric chart reviewer. This article sheds light on how some have perfected these reviews within their department.
Howard Rodenberg, MD, MPH, CCDS , describes how internal reviews can be used to identify repeated coding errors and prevent payment penalties due to Patient Safety Indicators (PSI) and hospital-acquired conditions (HAC).
Joe Rivet, Esq, CCS-P, CPC, CEMC, CHC, CCEP, CHRC, CHPC, CICA, CPMA, CAC, CACO , summarizes findings from recent Office of Inspector General audits that highlight improper billing of high-level inpatient stays. He also outlines steps hospitals can take to prevent billing errors due to upcoding.
A recent Office of Inspector General audit estimates that Medicare improperly paid inpatient hospitals $267 million over a two-year period for transfer services incorrectly billed as discharges. Judith Kares, JD , analyzes documentation and billing rules for acute and post-acute transfers.
The evolution of the role of clinical documentation integrity (CDI) specialists and their impact on coders has changed the landscape of inpatient coding departments. Learn about how to effectively collaborate with CDI professionals when conducting physician queries.
It’s always been easy to show financial return on investment for inpatient CDI endeavors, but the monetary value of outpatient programs is increasing dramatically year after year, making outpatient CDI reviews more attractive to many healthcare organizations.
Review quality reporting metrics such as length of stay and mortality indexes that you can use to assess patient outcomes and improve revenue cycle processes.
It’s common to see CDI job listings that require applicants to be registered nurses. Often an RN credential is not listed as being “preferred,” but required. There are risks, however, with only seeking candidates from this one background.
Let’s face it: Our organizations are under tremendous scrutiny. As the healthcare dollar shrinks, all payers strive to minimize patient care expenses to maintain profit margins.
Ischemic heart disease has a multifactorial etiology and can be prevented from developing in populations primordially and in individuals at high risk by primary prevention.
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.
Facilities that are not leveraging CDI efforts for denials management and tracking denials as a key performance indicator (KPI) should consider doing so. Denials are the framework for identifying gaps in provider documentation and are a surefire approach to tailoring physician education that is meaningful.
Though the adoption of outpatient CDI has been growing steadily over the years, it’s not always easy to prove the return on investment for such efforts.
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.
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.
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.
Recently, we have seen a rise in the documented diagnosis of malnutrition at our inpatient facilities. Malnutrition is highly reviewed among auditors and just as commonly denied among payers. I want to share the most recent coding updates and best practice guidelines with you.
In the 2021 Medicare Physician Fee Schedule final rule, CMS announced new HCPCS add-on code G2211 for visit complexity inherent to E/M services. Julia Kyles, CPC, describes when and how to report G2211 with E/M codes 99202-99215.
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.
One concern CDI professionals and inpatient coders say they struggle with is physician engagement and education. Without an engaged physician staff, CDI and coding efforts will languish with unanswered queries and subpar documentation practices.
I received a note from Diane Matysik, a CDI supervisor for Ascension Health in Duluth, Minnesota, who asked a question near and dear to my emergency department (ED) heart: If a patient suffers an out-of-hospital cardiac arrest and is resuscitated before arrival in the ED, should the scenario be described with an ICD-10-CM Z code?
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.
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.
A few years ago, there was a change of attitude within seizure medicine that manifested itself as new terminology. The older term “pseudoseizure” was replaced by the phrase “psychogenic non-epileptogenic seizure.”
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.
Departmental silos are prevalent in the healthcare world and can lead to unvoiced frustrations and counterproductive work. Different organizations have different approaches to breaking down these walls, often through regular interdepartmental meetings or newsletters.
Coronaviruses are a large family of viruses that cause illnesses ranging from the common cold to more severe diseases such as Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS). The SARS-CoV-2 coronavirus, which had not previously been identified in humans, is the strain that was discovered in 2019. It causes novel coronavirus disease (COVID-19) and is responsible for the current global pandemic.
Physicians can be a bit prickly at times. While this statement intentionally downplays the behavior of (hopefully) only a few doctors, I believe that most physicians are amenable to CDI concepts. While attempting to effect change in physician documentation patterns, I’ve learned many lessons from my medical staff and from other creative CDI colleagues.
Joel Moorhead, MD, PhD, CPC , writes that certain clinical indicators provide strong support for a diagnosis of acute-on-chronic congestive heart failure (CHF) in adults. Because of this, it’s important for inpatient coders to familiarize themselves with baselines and clinical indicators in order to ensure accurate reporting.
To deal with the rising rate of infection and increased hospital admissions for extraordinarily sick patients due to the novel coronavirus (COVID-19), CDI teams have had to act quickly by adapting to remote work, modifying CDI practices, and more.
Cheryl Manchenton, RN, BSN, CCDS, CPHM, writes that when it comes it reporting novel coronavirus (COVID-19), our understanding of it and its sequelae/manifestations is continually evolving. There is one “manifestation” of COVID-19 that is of interest for experimental treatment: cytokines.
It’s been nearly three years since HCPro’s last survey dedicated to query practices . Since querying is a constant and continuous aspect of CDI work, a 16-question survey focused on physician queries was recently conducted. Because of the survey’s limited length, it concentrated primarily on productivity and compliance concerns.
Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC , gives guidance to CDI teams working on clinical validation, denials prevention, and appeals processes to help ensure proper reimbursement for their hospitals.
Sarah A. Nehring, CCS, CCDS, writes that an inpatient coder’s first concern regarding the reporting of novel coronavirus (COVID-19) is to code all confirmed cases and only confirmed cases. In this article, Nehring details guidelines on how to accomplish this.
Laurie L. Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , reviews Coding Clinic , First Quarter 2020, guidance, which includes topics such as reporting vaping-related disorders, malnutrition, and bariatric procedures.
Clinical validation reviews and queries ensure that the documented diagnoses and clinical indicators hold up to inspection. This article gives an overview on processes and templates, top queried diagnoses, and physician engagement to help CDI teams perfect their clinical validation efforts.
All queries, regardless of their origin, are bound to follow the “ Guidelines for Achieving a Compliant Query Practice .” In order to ensure queries stand up to outside scrutiny and are effective, many CDI and inpatient coding leaders have put query audit practices in place for their departments as they bring on new team members.
Pulmonary hypertension is a complex, progressive disease that affects both children and adults, and leads to significant morbidity and mortality. In this article, Amy Sanderson, MD , reviews this disease to help ensure proper inpatient reporting and more precise queries.
Sarah Nehring, CCS, CCDS, says that strokes are complicated, which is why it is important for inpatient coders to be familiar with the brain’s anatomy and the clinical concepts of a stroke in order to report the most accurate ICD-10-CM codes.
Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, CCDS-O , takes a closer look at the main topics addressed in a recently published Coding Clinic Advisor FAQ, including ICD-10-CM coding for antibody testing, virus signs and symptoms, and comorbidities related to the novel coronavirus (COVID-19).
Globally, millions of people have been infected by the novel coronavirus (COVID-19), according to the Centers for Disease Control and Prevention (CDC) . There have been hundreds of thousands of confirmed COVID-19 cases, and many thousands of deaths, just in the United States
Trey La Charité, MD, FACP, SFHM, CCS, CCDS , writes that one area of risk unique to CDI and coding staff is the physician query. While the creation of the individual physician query usually garners most of the attention, maintenance of query compliance is equally important and frequently overlooked.
Modifier -22 frequently causes compliance headaches for revenue cycle professionals. Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC , reviews CPT reporting requirements for this commonly misused modifier to ensure that your physicians are being appropriately reimbursed for increased procedural work.
Amy Sanderson, MD , writes that cerebral edema and brain compression are the result of significant brain abnormalities that can be life-threatening, and it’s important for clinicians to recognize and treat these conditions promptly. Properly documenting these diagnoses in the medical record is important to accurately reflect just how sick these patients are.
Why delve into psychiatric record review? For some programs, the expansion into psychiatric units or facilities may be driven by the needs of the patient population, says Rhonda Mark, RN, BS, CCDS , a CDI specialist at Cleveland Clinic Indian River Hospital in Vero Beach, Florida.
Kay Piper, RHIA, CDIP, CCS, says exciting changes to ICD-10-CM are published in an often-overlooked document called the Addenda. It lists additions, revisions, and deletions to the Alphabetical Index and Tabular List. This might seem mundane until you realize the changes’ potential effect on coding and CDI.
William E. Haik, MD, FCCP, CDIP , details guideline changes regarding the diagnosis and treatment of adults with community-acquired pneumonia and provides criteria to clinically validate a diagnosis of Gram-negative and methicillin-resistant Staphylococcus aureus (MRSA) pneumonia.
Julian Everett, RN, BSN, CDIP , says that 2020 should be the year when more CDI programs and inpatient coding teams ponder the idea of expanding into reviewing obstetrics. In this article, Everett details key areas to consider when starting these reviews, including hiring staff that have experience in obstetrics, conducting case sample assessments, and providing education on coding guidelines.
While the premise for quality programs is largely the same across the board, there are many programs and measures that fall under the “quality” banner. From readmissions to present on admission (POA) and patient safety indicators (PSI), CDI programs have a myriad of potential options in terms of record review focus.
As with any new clinical documentation integrity (CDI) initiative, there are many possible starting points for outpatient CDI. Review advice from healthcare professionals at Trinity Health on how to successfully implement an outpatient CDI program.
The fiscal year 2020 inpatient prospective payment system (IPPS) proposed rule threw gas on the population health fire when it proposed giving social determinants of health (SDOH) codes more weight as complications/comorbid conditions (CC).
With the increased focus on clinical validation denials, more and more CDI professionals are finding themselves involved in the appeals-writing process and may initially feel a bit overwhelmed by the magnitude of the job. This article is part two of the two-part series covering best practices and appeal advice for those on the frontlines.
Sarah Nehring, CCS, CCDS , writes that CDI and coding professionals must understand the guidelines for coding myocardial infarctions (MI) as well as the clinical difference between type 1 MIs and type 2 MIs so they can be clinically validated, queried, and reported effectively to avoid negative reimbursement ramifications. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
With the increased focus on clinical validation denials, more and more CDI professionals are finding themselves involved in the appeals-writing process and may initially feel a bit overwhelmed by the magnitude of the job. This article will provide you with best practices and appeal advice for those on the frontlines.
As the cost of healthcare continues to skyrocket, payers are looking for ways to save and want to make sure that claims reflect correct information and that the care provided was clinically justified.
One of the most vexing challenges that CDI specialists have is how to engage physicians to completely and precisely document their patients’ conditions and treatments in the language required by ICD-10-CM, which is essential to risk adjustment.
One strategy for handling the confluence of confusion surrounding frequent criteria changes comes in developing a set of organizationwide clinical criteria for targeted, high-risk/high-volume diagnoses. This article discusses others’ experiences in developing standardized clinical indicators and guidelines at their facilities.
James S. Kennedy, MD, CCS, CDIP, CCDS , reviews updated policies in the 2020 Medicare Physician Fee Schedule final rule that will affect ICD-10-CM risk-adjustment reporting and documentation for facilities.
JustCoding’s sister publication, HIM Briefings, conducted a benchmarking survey to shed light on edit and denial management processes across the industry. Review findings from the survey to see how your organization compares to those across the industry.
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 many familiar ideas are often discussed—newsletters, tip sheets, organizational clinical definitions, and the like—not every physician responds the same way to the same educational techniques. Here’s what the CDI community had to say regarding this issue.
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.
One thousand eighty cases of respiratory illnesses and 18 deaths brought on by vaping have been reported in the U.S. as of October 1, according to the Centers for Disease Control and Prevention. Review provider documentation and ICD-10-CM reporting for vaping-induced illnesses. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
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.
I can teach CDI to anyone. Just get the providers in a room with me; they don’t even have to be willing participants. While I have heard many times that physicians only listen to other physicians, I believe my success has less to do with the initials at the end of my name and more with the fact that the CDI cause is just, and I’m passionate when I teach.
The fiscal year 2020 ICD-10-CM Official Guidelines for Coding and Reporting provide instructions for healthcare professionals on how to appropriately report complex diagnoses. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , writes about significant guideline updates that will impact facilities starting October 1.
Internal audits can reveal inconsistencies in provider documentation and coding, reporting errors, and fraudulent billing practices. Review internal auditing basics and advice from regulatory experts on how to effectively educate providers on audit findings. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
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.
