The annual incidence of an initial venous thromboembolism (VTE) event, either a pulmonary embolus (PE) or a deep vein thrombosis (DVT), is approximately 0.1% in the United States, with the highest incidence among the elderly and a recurrence rate of about 7% at six months.
Each new CMS fiscal year, MS-DRG weight and classification changes in the CMS IPPS final rule are closely scrutinized by coders and CDI specialists to identify any potential impact on documentation capture and code assignment processes.
ICD-10 implementation is almost here, but coders are still facing resistance from physicians. W. Jeff Terry, MD, highlights ICD-10 challenges from the physician perspective, while Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, responds from a coder’s point of view.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, explains how to identify anemia in documentation for OB/GYN patients and which ICD-9-CM and ICD-10-CM should be reported.
Coding, documentation, and diagnoses aren’t always clear-cut, which can challenge even experienced codes. Review the coding and documentation requirements for encephalopathy, stroke, and anemia.
In the third part of our series on Patient Safety Indicator 90, we focus on inclusions, exclusions, and coding and documentation vulnerabilities for PSI 7.
ICD-10-CM will still allow coders to report unspecified codes. However, coders will not have that option in ICD-10-PCS. Every character has to have a value, which will lead to an increase in surgical queries.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, reviews the different methods of fetal monitoring and what coders will need to look for in documentation to report them.
Our friends at the Association of Clinical Documentation Improvement Specialists (ACDIS) and 1,400 or so of their closest friends have descended on San Antonio for their annual conference. Things did...
A complication basically refers to an unexpected result, outcome, or event. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, Cheryl Ericson, MS, RN, CCDS, CDIP, and Trey La Charité, MD , detail when to report a complication and highlight the differences in complication coding between ICD-9-CM and ICD-10-CM.
Myths and misinformation about query practices still remain. Cheryl Ericson, MS, RN, CCDS, William E. Haik, MD, FCCP, CDIP, CDIP, and Nelly Leon-Chisen, RHIA, provide a refresher on how and when to query physicians.
Clinical documentation improvement (CDI) specialists must understand CMS pay-for-performance measures in order to improve data quality . Shannon Newell, RHIA, CCC, AHIMA-approved ICD-10-CM/PCS trainer, Steve Weichhand, and Sean Johnson explain how Patient Safety Indicator 90 is measured and what role CDI specialists play in capturing data for this measure.
The American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS) released joint physician query instructions in Guidelines for Achieving a Compliant Query Practice in February 2013.
Coders and clinical documentation improvement specialists often focus on different information when reviewing documentation for heart disease. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Cheryl Ericson, MS, RN, CCDS, CDIP, highlight the different perspectives.
Coding professionals may inappropriately assign codes from parts of the medical record where the doctors, early in the workup of a complex patient, were describing differential diagnoses in their evaluation of the patient. Robert S. Gold, MD, discusses whether coders should report every diagnosis mentioned in a patient’s chart.
Coronary artery disease (CAD) develops when the arteries that supply the blood to the heart muscles become hardened and narrowed due to a buildup of cholesterol and other materials, such as plaque, on their inner wall. It's also called atherosclerosis.
