CMS developed the National Correct Coding Initiative (NCCI) to control improper coding and potentially inappropriate payment of Part B services. Review NCCI basics to ensure compliance with the latest coding policies.
Healthcare professionals often struggle to define the role of CDI in their organization. Marlene Goodwin-Esola, MSN, RN-C, CV , clarifies the role of CDI specialists and professionals in related disciplines who contribute to documentation improvement efforts.
The principal diagnosis is key to prioritizing subsequent reviews, identifying potential quality measure inclusion, and pinpointing query opportunities. Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , breaks down guidance for selecting the principal diagnosis.
Clinical quality measures are tools used by healthcare professionals to measure or quantify processes and outcomes. Audrey Howard, RHIA, and Susan Belley, RHIA, CPHQ, describe documentation elements that affect quality metrics and how to incorporate them into an audit workflow.
Acute hospital care at home is reimbursed the same as if the patient was physically an inpatient in a hospital, with the same documentation requirements, quality measures, and medical necessity guidelines. Learn how strengthening CDI's role in these programs can help support their success.
The terms “admission” and “observation” are often confused. Dawn Valdez, RN, LNC, CCDS, CDIP , distinguishes between these terms and evaluates ICD-10-CM coding for patients who begin in observation and are later admitted to the hospital for more intensive care.
Lena Wilson, MHI, RHIA, CCS, CCDS , takes a deep dive into the CDI/coding reconciliation process and outlines tips that coders and CDI professionals can apply to improve this process.
Coding and billing professionals must ensure that medical record information is accurate, up to date, and compliant. In this article, Holly Cassano, CPC, CRC , defines late entries, corrections, and addendums, and explains the proper methods used to alter health records while maintaining Medicare compliance.
Kathy Shumpert, MSN, RN, CCDS, writes about the evolution of the denials and appeals process at her facility and discusses tactics to improve communications and efficiency.
Pregnancy causes changes to the immune system that increase the risk of infection and sepsis during pregnancy, labor, and the puerperium. Sarah Nehring, BS, RHIT, CCS, CCDS , analyzes ICD-10-CM documentation and coding for sepsis after childbirth.
Social determinants of health ICD-10-CM codes have become more of a hot topic in the CDI world over the past few years. Review guidance for reporting personal circumstances such as income, wealth, and education that impact health and wellbeing.
A properly calibrated audit tool is key to uncovering educational opportunities for coding and CDI professionals. Dawn Valdez, RN, LNC, CDIP, CCDS, outlines questions for determining an audit focus and for querying providers when documentation is insufficient to support medical necessity.
Respiratory failure occurs when the body is unable to provide oxygen to or remove carbon dioxide from the body. Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , breaks down documentation and ICD-10-CM coding for acute and chronic respiratory failure.
Many healthcare systems are looking at how to expand their CDI program to include outpatient and ambulatory settings. Jennifer Boles, BS, COC, CRC, CCDS-O, explores her ambulatory CDI program’s success and offers advice for those looking to expand.
Coders must be familiar with ICD-10-CM reporting guidelines for common neurological conditions. This article unpacks recent updates to the nervous system chapter of ICD-10-CM including 14 new codes for autonomic conditions and fatigue syndromes.
Audits are crucial to helping CDI and coding teams stay up to date with the fast pace of medicine and continual changes to coding guidelines. Dawn Valdez, RN, LNC, CDIP, CCDS , writes about best practices for auditing and application of audit findings .
Many healthcare systems are looking at how to expand their CDI program to include outpatient and ambulatory settings. Jennifer Boles, BS, COC, CRC, CCDS-O, explores her ambulatory CDI program’s success and offers advice for those looking to expand.
Social determinants of health such as economic stability and access to education significantly impacting health outcomes. Kim Conner, BSN, RN, CCDS, CCDS-O , outlines potentially confusing ICD-10-CM guidelines and documentation challenges that complicate coding for social determinants.
Debridement is used to treat serious or chronic wounds that do not heal with standard treatment. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG , describes five types of debridement and how to report these procedures in ICD-10-PCS.
Coders must be familiar with updates to the ICD-10-CM/PCS code sets for fiscal year 2023 . Audrey Howard, RHIA , reviews new codes and reporting guidelines for dementia, care complications, and vascular procedures as well as updates to MS-DRGs.
Social determinants of health such as economic stability and access to education significantly impacting health outcomes. Kim Conner, BSN, RN, CCDS, CCDS-O , outlines potentially confusing ICD-10-CM guidelines and documentation challenges that complicate coding for social determinants.
Malnutrition includes undernutrition, inadequate vitamins or minerals, overnutrition, obesity, and diet-related noncommunicable diseases. Inpatient coders must be familiar with clinical criteria and ICD-10-CM coding for this condition as it is frequently the focus of clinical validation audits. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Inpatient coders have malnutrition on their mental list of diagnoses at risk of audits. Learn how to effectively work with dieticians and CDI staff to ensure accurate documentation and ICD-10-CM coding for malnutrition.
Reconciling CDI reviews and queries against final coding is an important but sometimes overlooked step. Use these expert tips to refresh or develop your organization's CDI and coding reconciliation process.
Sepsis and systemic inflammatory response syndrome are historically difficult to document and report in ICD-10-CM. Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , breaks down sepsis definitions and outlines a process for query creation.
Hospital coders must be able to determine the reason for an admission and to differentiate conditions present on admission (POA) from those that develop during an inpatient stay. Learn how to effectively decipher documentation to identify the principal diagnosis and conditions that were POA.
In an industry that changes both quickly and frequently, keeping staff educated is important not only for your healthcare system, but for your employees’ professional growth. Catherine Sheika, BSN, RN, CCDS, writes about coding and team-building games that make even the driest topics more engaging.
Sepsis and systemic inflammatory response syndrome are historically difficult to document and report in ICD-10-CM. Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , breaks down sepsis definitions and outlines a process for query creation.
Every organization’s priorities will differ, but any outpatient CDI program must determine how to measure the improvement associated with its efforts. Outpatient CDI will directly contribute to the facility’s overall quality performance and risk adjustment models.
by Kim Conner, BSN, RN, CCDS, CCDS-O In our ever-changing landscape of healthcare, quality and prevention continue to drive the way we deliver care to our patients. As a result, social determinants...
Coding a chart with a sepsis diagnosis requires careful attention to detail. Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , reviews sepsis documentation, ICD-10-CM coding requirements, and quality measures for public reporting.
Revenue leakage can be caused by a number of factors including late filings, inconsistent documentation, and inaccurate coding. Fran Jurcak, MSN, RN, CCDS, CCDS-O , describes proactive strategies that coding professionals can use to address mid-revenue cycle leakage.
Aspiration pneumonia is a lung infection caused by inhaled oral or gastric contents. Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , breaks down documentation and ICD-10-CM coding requirements for aspiration pneumonia.
As a result of the pandemic, delivering consistent, quality CDI education has become more challenging. My hospital has been no exception, and although adapting has not been easy, it is doable.
Inpatient coders must be familiar with different types of denials such as those due to clinical validity concerns. Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM , outlines components of a clinical validation denial and tools used to craft a clinical validation appeal.
Reviewing a sample of claims for clinical validity and coding accuracy can seem like a daunting task. Kaitlin Loos, RN, BSN, CDI auditor, and Molly Siebert, RHIA, CCDS, CDI specialist, describe their individualized review processes.
Inpatient coders must be familiar with different types of denials such as those due to clinical validity concerns. Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM , outlines components of a clinical validation denial and tools used to craft a clinical validation appeal.
Physician documentation of heart failure must specify the type and severity of the illness to apply the most accurate code. Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM , breaks down clinical documentation and ICD-10-CM coding for four types of heart failure.
The primary purpose of CDI work is to review medical records to increase the accuracy and specificity of provider documentation. Review the primary responsibilities of a CDI specialist including documentation review, querying, and physician education.
Patients are often admitted for acute conditions and experience additional issues affecting their care and treatment plan during the encounter. Ashayla Stephens, MHA, RHIA, CCS , and Audrey Howard, RHIA , describe the process of validating multiple diagnoses documented within the health record. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CDI specialists must be able to apply both clinical and coding knowledge in order to discern relevant clinical conditions, and they must be able to analyze the quality of provider documentation and identify any gaps or inconsistencies in information between the health record and the associated data.
Acute kidney injury (AKI) is a sudden and temporary loss of kidney function, while acute tubular necrosis (ATN) is a kidney injury characterized by acute tubular cell injury and dysfunction.
One of the biggest components of a leader’s role is to track, trend, and report on the department’s performance. Learn strategies for balancing priorities and time constraints and presenting key performance indicators to leadership.
Computer-assisted coding (CAC) technology analyzes healthcare documentation and selects codes based on specific phrases and terms. Review the pros and cons of using this software to perform inpatient coding and billing functions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Due to the complex nature of sepsis, some cases require querying the provider prior to assigning ICD-10-CM/PCS codes. Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM , breaks down inpatient coding and querying for sepsis.
