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.
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.
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.
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.
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...
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.
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.
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.
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.
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.
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.
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.
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.