Our experts answer questions about coding for controlled puerperium diabetes and endoscopic procedures as well as provide suggestions for referring to prior encounter information in queries.
Shelley C. Safian, PhD, MAOM/HSM/HI, RHIA , explains ways administration can establish an organizational culture of legal and ethical responsibilities to maintain compliance and honor patients and staff.
Q: A physician documented metabolic encephalopathy on a postoperative patient who was sedated on a vent, but because there were not documented responses while on the vent, I was unable to clinically validate the encephalopathy while the patient was sedated on the vent. How would a coder query this diagnosis for validity?
Sepsis is one of the most prevalent diagnoses necessitating hospital admissions in the United States, and unfortunately, sepsis denials are also prevalent and on the rise. John Williams, RN, BSN, CCDS, clarifies how to ensure all indicators and findings of sepsis are present and valid for each inpatient admission.
The concept of expanding clinical documentation integrity (CDI) programs into the outpatient setting is not new but the COVID-19 pandemic threw a wrench into a lot of organizations’ expansion plans. Now it might be time for organizations to revisit the idea. Review the steps to expand into outpatient CDI.
Most facilities find acute respiratory failure to be a commonly denied diagnosis. Sharme Brodie, RN, CCDS, CCDS-O, explores when the circumstances of admission and the focus of care support the condition for coding.
Without proof that services rendered were medically necessary, third-party payers are unlikely to approve claims for reimbursement. With tips from Shelley C. Safian, PhD, RHIA, CCS-P, COC, COC-I , medical coding professionals can use ICD-10-CM codes to prove medical necessity. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Medical decision-making (MDM) documentation has gained increased importance in recent years to justify a visit’s medical necessity. Review CMS’ MDM table and guidelines to take the guesswork out of your coding.
Without proof that services rendered were medically necessary, third-party payers are unlikely to approve claims for reimbursement. With tips from Shelley C. Safian, PhD, RHIA, CCS-P, COC, COC-I , medical coding professionals can use ICD-10-CM codes to prove medical necessity.
CMS recently released an updated MLN fact sheet reminding providers about documentation requirements for requests from its Comprehensive Error Rate Testing (CERT) program.
A few years ago, providers started using new guidelines for their office/outpatient services that based the level of service on medical decision-making (MDM) or time on the date of the face-to-face encounter. This article focuses on office/other outpatient coding basic guidelines that apply to all level-based E/M codes. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
The success of coding and CDI departments depends on collaboration with multiple entities. Laurie L. Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , illuminates how to promote healthy partnership.
Nancy Reading, RN, CPC, CPC-P, reviews the Phoenix Sepsis Score, a new set of clinical parameters to define and diagnose pediatric sepsis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Shelley C. Safian, PhD, MAOM/HSM/HI, RHIA , explains ways administration can establish an organizational culture of legal and ethical responsibilities to maintain compliance and honor patients and staff.
JoAnn Baker, CCS, CPC, COC , defines sepsis and septic shock, and delves into the emerging initiative to integrate AI into the diagnosis and treatment process.
Kathy Dorich, MSN, RN, CCDS, CPHQ , explains two types of DRG reconciliation processes that she has implemented to alleviate conflict between coding and CDI departments.
by Sareem Wani, MD I recently took a personality test and, after answering a series of questions based on various case scenarios, learned that my strengths are in collaboration and education. It took...
JoAnn Baker, CCS, CPC, COC , defines sepsis and septic shock, and delves into the emerging initiative to integrate AI into the diagnosis and treatment process.
Managing chronic conditions requires involvement from many parties, making documentation challenging. Assess how to improve documentation and reimbursement for chronic conditions with tips provided by Arta Kelmendi-Doko, MD, PhD . Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Pressure injuries, which can lead to a patient safety indicator (PSI), require clear documentation and coordination among coding, CDI, and clinical departments. Katherine Siemens, RN, BSN, CMSRN, CCDS , evaluates how poor coordination could result in a PSI being incorrectly reported.
Merle Zuel, RN, CCDS , explains how healthcare leaders can improve in their roles by understanding all coding and clinical data available and knowing how to analyze it.
by Jess Fluegel It is a truth universally acknowledged that a CDI department, in possession of a part-time physician advisor who is already stretched too thin, may be in want of provider engagement...
Pressure injuries, which can lead to a patient safety indicator (PSI), require clear documentation and coordination among coding, CDI, and clinical departments. Katherine Siemens, RN, BSN, CMSRN, CCDS , evaluates how poor coordination could result in a PSI being incorrectly reported.
Educating clinical staff on proper documentation of mechanical ventilation can avoid compliance issues and support accurate reimbursement. This article clarifies the complications of reporting mechanical ventilation in ICD-10-PCS.
Kate Siemens, RN, BSN, CMSRN, CCDS , offers tips on how coders and CDI can assess patient safety indicators to improve reporting accuracy and increase quality of care.
The pediatric population is smaller and involves different clinical and nuances, but this often-underdeveloped area of coding can be a source of missed revenue if left uninvestigated.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS, analyzes the challenges that both inpatient and outpatient CDI specialists encounter and offers advice to lessen provider opposition to participating in outpatient CDI.
Educating clinical staff on proper documentation of mechanical ventilation can avoid compliance issues and support accurate reimbursement. This article clarifies the complications of reporting mechanical ventilation in ICD-10-PCS.
Many CDI professionals are familiar with the saying that, since CDI is “already in the chart,” they can easily pick up a new review lens. The reality, however, is that each new responsibility can put a damper on staff bandwidth and productivity.
This article explains the quality metrics of hospital-acquired infections and accidental punctures and lacerations, and details how collaborative efforts can reduce these risks.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS , analyzes the challenges that both inpatient and outpatient CDI specialists encounter and offers advice to lessen provider opposition to participating in outpatient CDI.
Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , summarizes guidance from the 2024 first quarterly release of Coding Clinic , including reporting for postoperative complications, non-traumatic kidney injuries, and vertebral artery dissection.
Shannon Oitker, MSN, RN , reviews the nine MS-DRGs for ventilator use, explains how DRGs are designed, and assesses whether hospitals are receiving adequate reimbursement for ventilation services.
This article explains the quality metrics of hospital-acquired infections and accidental punctures and lacerations, and details how collaborative efforts can reduce these risks.
TaraJo Vaught, MSN, RN, CCDS , shines a light on the crucial roles played by coding and CDI specialists, compares their respective realms, and offers insights for transitioning between them.
Although every professional may be different, there are a few tricks of the trade to building the right garden and letting your CDI department show off some of that natural talent.
Artificial intelligence (AI) has burst on the scene with numerous clinical and coding applications for providers. This article looks at how the technology can be used and where human oversight is still required.
Penny Jefferson, MSN, RN, CCDS, CCDS-O, CCS, CDIP, CRC, CHDA, CRCR, CPHQ , explains how professional development in CDI is a journey, demanding integration of specific knowledge, continuous learning, and adaptability.
Amanda Vincent, MBA, CCS, CPC, CCDS, CRC , analyzes various types of postprocedural complications, such as respiratory failure, infection, ileus, shock, and offers direction on how to report them.
While certifications specific to CDI are by no means a requirement to get into the CDI field, they have grown to become a rite of passage for many CDI professionals.
TaraJo Vaught, MSN, RN, CCDS , shines a light on the crucial roles played by coding and CDI specialists, compares their respective realms, and offers insights for transitioning between them.
Nancy Reading, RN, CPC, CPC-P , explains how employing clinical and coding criteria for assigning or auditing ICD-10-CM codes for malnutrition can have a significant impact on reimbursement. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
