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.
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.
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.
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.
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.
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.
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.
Sarah Nehring, CCS, CCDS , writes that CDI and coding professionals must understand the guidelines for coding myocardial infarctions (MI) as well as the clinical difference between type 1 MIs and type 2 MIs so they can be clinically validated, queried, and reported effectively to avoid negative reimbursement ramifications. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
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.
As the cost of healthcare continues to skyrocket, payers are looking for ways to save and want to make sure that claims reflect correct information and that the care provided was clinically justified.
One of the most vexing challenges that CDI specialists have is how to engage physicians to completely and precisely document their patients’ conditions and treatments in the language required by ICD-10-CM, which is essential to risk adjustment.
One strategy for handling the confluence of confusion surrounding frequent criteria changes comes in developing a set of organizationwide clinical criteria for targeted, high-risk/high-volume diagnoses. This article discusses others’ experiences in developing standardized clinical indicators and guidelines at their facilities.
James S. Kennedy, MD, CCS, CDIP, CCDS , reviews updated policies in the 2020 Medicare Physician Fee Schedule final rule that will affect ICD-10-CM risk-adjustment reporting and documentation for facilities.
JustCoding’s sister publication, HIM Briefings, conducted a benchmarking survey to shed light on edit and denial management processes across the industry. Review findings from the survey to see how your organization compares to those across the industry.
Rachelle Musselman, BSN, RN; Jorde Spitler, BSN, RN; Daniel Lantis, BSN, RN; Joseph E. Ross, MD; and Thomas A. Taghon, DO, MHA, review their experience with implementing pediatric heart failure criteria at Dayton Children’s Hospital.
Julian Everett, RN, BSN, CDIP, writes that early recognition of sepsis in pediatric patients, along with accurate reporting, is vital to the future of healthcare. With the goal of improving patient outcomes through documentation, Everett outlines her experience in providing documentation education to physicians.
While many familiar ideas are often discussed—newsletters, tip sheets, organizational clinical definitions, and the like—not every physician responds the same way to the same educational techniques. Here’s what the CDI community had to say regarding this issue.
While “myocardial ischemia” is a familiar term to CDI professionals and inpatient coders, the term “myocardial injury” does not share the same widespread recognition. In this article, Adriane Martin, DO, FACOS, CCDS , deciphers the clinical criteria and reporting guidelines for capturing myocardial injuries and demand ischemia.
One thousand eighty cases of respiratory illnesses and 18 deaths brought on by vaping have been reported in the U.S. as of October 1, according to the Centers for Disease Control and Prevention. Review provider documentation and ICD-10-CM reporting for vaping-induced illnesses. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
In part one of this two-part series, Sharme Brodie, RN, CCDS , reviews the recent guidance from Coding Clinic , Second Quarter 2019, including cardiac conditions, transplants, and more.
I can teach CDI to anyone. Just get the providers in a room with me; they don’t even have to be willing participants. While I have heard many times that physicians only listen to other physicians, I believe my success has less to do with the initials at the end of my name and more with the fact that the CDI cause is just, and I’m passionate when I teach.
Internal audits can reveal inconsistencies in provider documentation and coding, reporting errors, and fraudulent billing practices. Review internal auditing basics and advice from regulatory experts on how to effectively educate providers on audit findings. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The fiscal year 2020 ICD-10-CM Official Guidelines for Coding and Reporting provide instructions for healthcare professionals on how to appropriately report complex diagnoses. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , writes about significant guideline updates that will impact facilities starting October 1.
Sarah Nehring, CCS, CCDS, says that the last thing a query writer wants is to provoke a defensive response, but in the current healthcare environment, CDI specialists, clinical, and inpatient coding staff need to think defensively. In this article, Nehring outlines five items to remember when it comes to defendable queries, documentation, and coding.
Cathy Farraher, RN, BSN, MBA, CCM, CCDS, writes that CDI professionals can work to reduce the incidence of physician query fatigue and gives recommendations to help improve provider response rate while reducing query frustration.
Tamara Hicks, RN, BSN, MHA, CCS, CCS, ACM-RN, CCDS-O , explains how her organization implemented a CDI career ladder and why it’s an important step for hospitals looking to expand their coding and CDI departments.
When you work in the CDI program of a medical facility, you are continually thinking of ways to elicit improved documentation from the medical staff. You also spend a fair amount of time lamenting why some physicians or service lines seem to ignore all educational efforts regarding the importance of explicit and accurate documentation. “If it is important to us,” you might say, “why is it not to them?”
Before starting an ambulatory or outpatient clinical documentation improvement (CDI) program, those tasked with the project must first create some universal definitions, so everyone is on the same page and speaking the same language.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS , explains why physicians may feel that coding and CDI professionals are asking too much and offers potential solutions to ease workplace tensions.
Adriane Martin, DO, FACOS, CCDS , writes about how to accurately capture and report social determinants of health to improve patient outcomes and decrease costs. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Keeping up with commercial payer requirements can stump any revenue integrity department, and commercial payer audits can be an especially tough puzzle to solve. Review advice from experts on improving internal processes for dealing with commercial audits.
In 2013, “Guidelines for Achieving a Compliant Query Practice,” a collaboration between AHIMA and ACDIS, was published. It has served as the industry guideline for the establishment of best practices surrounding queries. The 2019 update reinforces the information set forth in the preceding practice briefs while also introducing some newer guidelines reflective of today’s healthcare environment.
Before starting an ambulatory or outpatient CDI program, those tasked with the project must first create some universal definitions so everyone is on the same page and speaking the same language.
Acute kidney injury (AKI) and acute tubular necrosis (ATN) remain targets for both coding and clinical validation. Over the years, we’ve gleaned valuable insights from appealing hundreds of coding and clinical validation denials for AKI and ATN.
Patients who use oxygen at home for a primary respiratory condition typically present with some degree of respiratory failure. Howard Rodenberg, MD, MPH, CCDS , describes common documentation issues related to oxygen requirements for the diagnosis of acute respiratory failure.
Learn how ICD-10-CM coding accuracy, specificity, and compliance impacts provider performance in each of the four performance categories under the Merit-based Incentive Payment System (MIPS). Note : To access this free article, make sure you first register here if you do not have a paid subscription.
At the beginnings of inpatient coding and CDI, we had books like DRG Expert and Excel-based programs for MS-DRG selections. More than 10 years later, vendors are offering web-based technologies that use artificial intelligence and machine learning to make us even more productive in both coding and CDI. The real question, however, is how we can best leverage those technologies.
Sarah Nehring, CCS, CCDS, says that from the inpatient coding and CDI perspective, sepsis can be one of the trickiest diagnoses. In this article, she reviews 10 things coders wish physicians knew about sepsis documentation and coding.
A query is a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment for an individual encounter in any healthcare setting.
Although computer-assisted coding and natural language processing software has improved many aspects of daily CDI work, the technology requires ongoing oversight to ensure efficacy and accuracy. Therefore, CDI professionals, and even inpatient coders, need to be aware of the software’s potential pitfalls within the CDI department and develop tactics to overcome them.
