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.
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.
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.
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.
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.
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.
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.
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.
