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.
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.
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.
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 CDI specialists take on this role? Perhaps it might be a combination of the two.
Hospital medicine is a specialty that provides inpatient services for patients admitted to the hospital. Hospitalists are often called on to consult in regards to and to follow medical problems that occur during hospitalization for surgery, psychiatric hospitalizations, and obstetrical patients. Lois E. Mazza, CPC, explains how to correctly report hospitalist services.
The HIM profession is constantly changing, but HIM professionals are still responsible for maintaining the integrity of the health records. Lou Ann Wiedemann, MS, RHIA, FAHIMA, CPEHR, explains why HIM professionals can—and should—also play a role in clinical documentation improvement (CDI).
Coding managers and their team members sometimes must approach physicians in person regarding documentation. Clarification may be necessary, or perhaps you will need to coax the physician to complete certain records without further delay.
Physicians often use the acronyms IBS (which should indicate irritable bowel syndrome) and IBD (which should indicate inflammatory bowel disease) interchangeably even though they represent completely different conditions with different treatment and prognoses.
