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.
Our experts answer questions on reporting bronchiectasis and pneumonia with ICD-10-CM codes, coding diagnoses without clinical criteria, and documenting pressure injuries and wound care.
Because encephalopathy is a broad and complex syndrome that encompasses a wide range of brain disorders, Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , provides an in-depth review of the various forms of encephalopathy, their causes, clinical manifestations, diagnostic approaches, and treatment strategies, so that coders can effectively differentiate between the types and ensure accurate coding for optimal patient outcomes.
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.
Follow the career journey of Patricia Shirley, CPC-I, CPC , who started as a front office staff member and advanced through billing and coding roles before transitioning to the CDI field. Her experience highlights the benefits of adaptability and continuing education, demonstrating how a solid foundation in coding and compliance can help improve patient care and ensure accurate clinical documentation.
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 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.
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.
Coding certification can offer valuable benefits across various medical roles, improving accuracy and communication in clinical settings. Hassan Rao, MD, CPC, CCS , explores how coding knowledge can specifically enhance the effectiveness of CDI physician advisors in optimizing documentation and compliance.
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.
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.
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!
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.
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.
Coders are more aligned with CDI specialists than they may realize, as a deeper understanding of coding conventions enhances the accuracy and specificity of documentation. Sydni Johnson, BSN, RN, CCDS , and Suzanne Santellanes, BSN, RN, CCDS , shed light on how the tools of coders play a pivotal role in improving compliance strategies and ensuring the integrity of clinical records.
Our experts answer questions on coding COPD, smokers’ cough, and rectal fistulas in ICD-10-CM as well as provide recommendations for addressing malnutrition denials depending on the diagnosis criteria used (GLIM or ASPEN).
