The ICD-10 implementation delay has impacted training timelines for many providers. Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC , talks about how this time can be used to improve physician documentation, easing the transition for both coders and providers.
In an ideal world, all coders and CDI specialists would get along well and work together with minimal conflict. No one is going to agree all of the time, nor should they. A healthy, respectful dialogue can lead to a better understanding of the patient's clinical condition and result in more accurately coded records.
Coders and clinicians seem to speak different languages. CDI specialists often serve as the translators between clinicians and coders, so it's important that all three groups work together. Cheryl Ericson, RN, MS, CCDS, CDIP , AHIMA-approved ICD-10-CM/PCS trainer, Darice M. Grzybowski, MA, RHIA, FAHIMA , Jonathan Elion, MD, Kathy DeVault, RHIA, CCS, CCS-P , and William E. Haik, MD, FCCP, CDIP , offer tips for determining when to query.
Coders and clinicians seem to speak different languages. CDI specialists often serve as the translators between clinicians and coders, so it's important that all three groups work together.
The U.S. healthcare system is and will continue to be dependent on clinical codes and is thus equally dependent on accurate and complete clinical documentation. This relationship then makes documentation and coding truly dependent upon each other; without one you don’t have the other. It sounds plain and simple, but of course it is not.
These sample queries were adapted from The CDI Specialist’s Guide to ICD-10, created and donated by Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-Approved ICD-10-CM/PCS Trainer, CDI education director at HCPro in Danvers, Mass.
Coders live in a very difficult world. They want to do what is best for their organization based on the documentation they have, but sometimes the documentation is incomplete. The patient’s clinical picture can help coders decide when a condition rises to the level of a CC.
The number of patients using Medicare Advantage (MA) is rapidly growing, making Hierarchical Condition Categories (HCCs) an increasingly important concept for revenue cycle staff to understand in order to guarantee reimbursement.
In order to report accurate evaluation and management codes, coders need accurate, complete documentation. Coders can play a critical role in ensuring proper documentation. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, looks at methods coders can use to promote better documentation.
Documentation and medical necessity continue to be scrutinized by payers and auditors. Debbie Mackaman, RHIA, CPCO, and Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, explain how complete, accurate documentation of the entire patient encounter justifies the physician’s decision to admit.
Physicians are never going to like receiving queries from coders and CDI specialists. They really won't like all the queries they will receive after the transition to ICD-10.
Clinical queries serve a definitive purpose when documentation in the medical record is ambiguous, inconsistent, lacking specificity, or contradictory. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, explains why documentation improvement initiatives and heightened coder awareness of the need to query can be an asset or liability.
When an error occurs in coding, sometimes the coders miscodes a record, but in others, the documentation is deficient, leading to incorrect code assignment. Joy Strong, PMP, Donielle Bailey, RHIA, and Jill M. Young, CPC, CEDC, CIMC, discuss how good documentation and accurate coding go hand in hand.
How well could you code in ICD-10 using your current physician documentation? Do your physicians document the specificity and detail coders need to select the correct ICD-10-PCS code? Do your physicians document laterality, which coders will need for many ICD-10-CM codes?
CDI specialists shouldn’t focus on reimbursement, yet the reality is that improved documentation often does lead to higher payments for the hospital. Darice Grzybowski, MA, RHIA, FAHIMA, and Jon Elion, MD, offer tips on how CDI programs can mitigate ethical quandaries and demonstrate best practice.
Physicians often use different terms interchangeably when documenting sepsis. Robert Gold, MD , and Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, define the different terms and review when to query for additional clarification.
The best way to decrease denials or increase overturn rates begins with a compliant concurrent review of documentation. Marilyn S. Palmer, DO, and Jonathan G. Wiik, MSHA, MBA, review common Recovery Audit targets and provide tips for successfully appealing denials.
ICD-10-CM and ICD-10-PCS present different challenges, but both will require better documentation. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, Kathy DeVault, RHIA, CCS, CCS-P, Donielle Bailey , and Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, discuss some of the areas where coders will need more information to code in ICD-10.
Acute kidney injury (AKI) is an abrupt decrease in kidney function that includes—but is not limited to—acute renal failure. Garry L. Huff, MD, CCS, CCDS , and Brandy Kline, RHIA, CCS, CCS-P, CCDS , explain the clinical indicators of AKI and offers tips for composing queries.
Diagnostic conclusion statements don’t sufficiently capture the clinical context and medical necessity for inpatient admission. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, discusses the importance of clinical context and quality of clinical documentation in the medical record.
The 2014 draft ICD-10-PCS guidelines include a code for the usage of a robotic-assist device in surgery, something coders can currently report in ICD-9-CM. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , compares documentation requirements for coding robotic-assisted surgery in both ICD-9-CM and ICD-10-PCS.
It took some time to break down the wall between coders and CDI specialists at New Hanover Regional Medical Center in Wilmington, N.C. However, that wall eventually crumbled. Linda Rhodes, RN, BSN, CCDS, manager of CDI, says an increased emphasis on communication and respect is what did the trick.
The clinical documentation specialist role is relatively new, but can be a great place for coders. Lois Mazza, CPC, reveals why coders should consider taking on this role.
Hospital value-based purchasing (HVBP). It's the latest buzz phrase in the healthcare industry, and it's something in which all insurers are interested.
The ideal approach to ICD-10-CM/PCS preparation is capitalizing on the synergistic partnership between clinical documentation improvement and coding professionals. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, discusses how organizations can use this dynamic to improve preparations for ICD-10.
Clinical documentation improvement (CDI) initiatives often focus on inpatient documentation to ensure that documentation accurately reflects patient severity. Laura Legg, RHIT, CCS, explains how CDI efforts can also benefit outpatient coding.
Most hospitals have been overwhelmed by Recovery Auditor (RA) requests for documentation. So it's no surprise that the RAs themselves seem to be equally as burdened with the task of processing those records.
CMS and auditors are increasing scrutiny of CCs and MCCs. William E. Haik, MD, FCCP, CDIP, provides tips that coders can use to look for clinical evidence in the record before querying for these targeted conditions.
The increasing complexity of the healthcare reimbursement system, quality initiatives, and the transition to ICD-10-CM/PCS put clinical documentation improvement programs in the spotlight . Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, discusses the importance of documentation improvement specialists.
In February, AHIMA published an update to its 2010 query practice brief. The updated brief, Guidelines for Achieving a Compliant Query Practice, is the result of a joint effort between AHIMA and the Association for Clinical Documentation Improvement Specialists (ACDIS). ?
William E. Haik, MD, FCCP, CDIP, a practicing pulmonologist and director of DRG Review, Inc., in Fort Walton Beach, Fla., says he first became interested in coded data in 1986 after a local newspaper published his hospital’s costs, length of stay, and mortality rates for simple pneumonia. At the time, he was the only pulmonologist in the local area. The patients he treated were often those with multiple comorbidities as well as gram-negative bacterial pneumonia who had been transferred from two smaller facilities in the county.
Breast biopsies should be easy to code because coders have so few codes to assign, but it is one area where documentation is lacking. Stacie L. Buck, RHIA, CCS-P, RCC, CIC, reveals what key elements coders should look for in a breast biopsy note.
Everyone knows that CCs and MCCs are under scrutiny these days. However, that doesn't mean hospitals should err on the side of caution when reporting these conditions. William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Fla., provides several tips that coders can employ to look for clinical evidence in the record before querying for these targeted conditions.
Researcher Bill Rudman, PhD, RHIA, says he didn't fully understand the implications of codes that coders assign until he was sitting around a table with several criminal justice officials who said that coded data helps reduce violent crimes and recidivism.
The advent of electronic media is slowly but surely changing the way we access information. Hospitals and physicians are transitioning from paper and hybrid medical records to EHRs. Estimates indicate that nearly half of all Internet users send or receive email daily, according to EzineArticles.com .
Physician documentation must reflect severity of illness and risk of mortality for all patients. Robert S. Gold, MD, and Valerie Bica, BSN, RN, CPN, explain why pediatric patients require special attention in terms of clinical documentation improvement specialists.
We’re all thinking about documentation specificity needs in ICD-10-CM/PCS as we prepare of the October 1, 2014 compliance deadline. Increased communication between physicians and coders is paramount...
As Lucile Packard Children's Hospital in Palo Alto, Calif., implemented its EHR, the dreaded problem of copy and paste documentation began to rear its ugly head.
The ICD-9-CM guidelines state that it's unusual for two or more diagnoses to meet the definition of principal diagnosis. However, coders know this isn't exactly true, as the scenario tends to occur frequently.
Leading queries are frequently a topic of discussion among coding and clinical documentation improvement professionals. Glenn Krauss, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS, explains how to determine what constitutes a leading query and how to craft compliant queries.
Providers and coders seem to speak two different languages-clinical and coding. Providers already have issues parsing ICD-9-CM "coder speak," so how can you get them to understand ICD-10?
ICD-10-CM/PCS incorporates laterality, acuity, anatomical specificity, and a slew of additional combination and complication codes. Who will submit queries when this information is missing in a medical record? Will coders or clinical documentation improvement specialists take on this role? Cheryl Ericson, MS, RN, CCDS, CDI-P, and Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA, offer suggestions for determining who will submit queries.
If you’re worried about getting your physicians trained for ICD-10, you’re not alone. Thea Campbell, MBA, RHIA, Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, Donna Smith, RHIA, and Sue Belley , MEd, RHIA, CPHQ, offer tips and strategies to educate physicians about the new code sets.
