Kellie Halsted, MSN/MHA, RN, CCDS, CCM , writes about how her experience as a hospital case manager has given her additional insight into writing clinical validation appeal letters as a CDI specialist.
CMS recently published an infographic that defines social determinants of health (SDOH), explains the significance of capturing them, and lists which SDOH codes will go into effect October 1.
There is one tell-tale sign that fall is here: the October implementation of the ICD-10 coding updates. Courtney Crozier, MA, RHIA, CCS, CDIP , explains the highlights of the update for fiscal year 2024, including 395 new codes, 25 deletions, 22 revisions, and 131 new headers.
Reporting malnutrition correctly is a constant challenge that faces increasing payer scrutiny. Kate Siemens, RN, CMSRN, CCDS, defines malnutrition and its unique applicability to end-of-life care, documentation tips, and how to report associated conditions in ICD-10-CM. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
It can be advantageous for patients and facilities to capture social determinants of health (SDOH) alongside medical conditions. Joscelyn Thomas, RHIT , explains how incorporating screening tools into facilities can help providers and coders promote better health outcomes, reduce disparities, and increase patient engagement.
Building ICD-10-PCS codes for cardiovascular surgery can be tricky given the number of root operations that may apply. Sarah Gould, CPC , reviews cardiac anatomy and ICD-10-PCS guidelines for reporting cardiac insertion and bypass procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
A Journal of Hospital Medicine study published online in August found that decreases in readmission associated with CMS’ Hospital Readmission Reduction Program (HRRP) correlated with an increase in patient mortality for certain conditions.
Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , summarizes the highlights from the newest installment of Coding Clinic, which includes guidance on reporting pancytopenia, inherent conditions, ORIF, and neurally adjusted ventilatory assist devices.
There is one tell-tale sign that fall is here: the October implementation of the ICD-10 coding updates. Courtney Crozier, MA, RHIA, CCS, CDIP , explains the highlights of the update for fiscal year 2024, including 395 new codes, 25 deletions, 22 revisions, and 131 new headers.
Coders should take note of hundreds of updates to the tabular addenda that serves as an instruction guide to the 2024 ICD-10-CM code set. Both take effect October 1.
Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , summarizes the highlights from the newest installment of Coding Clinic, which includes guidance on reporting pancytopenia, inherent conditions, ORIF, and neurally adjusted ventilatory assist devices.
The heart is a restless organ whose constant rhythm is integral to normal bodily functions. Unfortunately, there are many maladies that can occur, as Linda Martien, CPC, CPC-I, COC, CPMA, CRC, explains through her review of normal cardiac pathophysiology and how to report common rhythm abnormalities in ICD-10-CM.
Diabetes mellitus is a common condition that occurs when a patient’s blood sugar (blood glucose) is consistently too high. Sarah Gould, CPC , delves into the disorder and covers how to report some of its many complications in ICD-10-CM. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The fiscal year (FY) 2024 IPPS final rule, released in August, provides updates on inpatient hospital reimbursement, ICD-10-CM/PCS coding and DRG changes, quality and reporting programs, and more.
The Centers for Disease Control and Prevention (CDC) announced the launch of its Hospital Sepsis Program Core Elements initiative on August 24. The program offers resources for hospitals to improve identification and management of sepsis.
With certain medical conditions, encountering differing opinions and discrepancies in provider documentation is inevitable. Deanne Wilk, MPS, RN, CCDS, CCDS-O, CDIP, CCS , reviews 10 diagnoses whose documentation commonly features discrepancies.
Hemodialysis involves diverting blood into an external machine, where it is filtered and returned to the body. Sarah Gould, CPC , describes the vascular surgical options for hemodialysis (fistulas and grafts), their various types, and how to report them in ICD-10-PCS. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Parkinson's disease is a chronic and progressive neurodegenerative disorder that affects the central nervous system. Debbie Jones, CPC, CCA , explains the symptoms, treatment, and how 2024 ICD-10-CM coding changes will affect reporting for this disease.
With certain medical conditions, encountering differing opinions and discrepancies in provider documentation is inevitable. Deanne Wilk, MPS, RN, CCDS, CCDS-O, CDIP, CCS , reviews 10 diagnoses whose documentation commonly features discrepancies.
The fiscal year 2024 IPPS final rule, released in August, provides updates on inpatient hospital reimbursement, ICD-10-CM/PCS coding and DRG changes, quality and reporting programs, and more.
Surgeons are often the toughest contingent of any medical staff with which a CDI program must make headway. Understanding a little surgeon psychology is the key to making positive inroads. Surgeons see themselves as “doers” or “fixers,” while they consider most other medical specialties as “thinkers” who are not “doers.”
Kate Siemens, RN, CMSRN, CCDS , offers her nursing and coding experience to explain postoperative ileus, a common complication after gastrointestinal surgery, and associated ICD-10-CM coding.
A recent study from Epic Research showed that the average length of provider notes increased, but note-taking time decreased since 2020. The study explains the reason for this change and the effect it has on providers.
Coders should take note of hundreds of updates to the tabular addenda that serves as an instruction guide to the 2024 ICD-10-CM code set. Both take effect October 1.
Shelley Safian, PhD, RHIA, CCS-P, COC, CPC-I, defines hand-assisted laparoscopic surgery (HALS) procedures and how to report them according to new guidance in the 2024 ICD-10-PCS guidelines. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: CMS recommends greater than 38°C as the upper limit temperature threshold for sepsis in the Sepsis-1 bundle, but our consulting group recommends greater than 38.3°C. What would you recommend using as the temperature threshold for diagnosing sepsis?
A June study in The Journal of the American Medical Association concluded that data collection and reporting efforts to comply with CMS inpatient hospital quality programs cost more than $5 million and took more than 100,000 personnel hours for a large hospital.
ICD-10-PCS provides many codes related to respiratory assistance, ECMO, and ultrasound for procedures for newborns/neonates. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , reviews these procedures and offers clinical coding scenarios to clear up confusion. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Kate Siemens, RN, CMSRN, CCDS , conducts an interview with Majed Gharfeh, MD, to offer a physician’s perspective on queries and tips on how coders can receive the best results from querying their providers.
The rise in remote work has enabled many healthcare systems to transition to a systemwide model. This change has left some CDI departments struggling to create a unified team. Learn from other facilities on how to overcome these challenges.
As the COVID-19 public health emergency has ended, audits are likely to pick up steam. To prepare for this increase in audit activity, it’s essential for providers and coders to examine both current and upcoming trends.
Shelley Safian, PhD, RHIA, CCS-P, COC, CPC-I, defines hand-assisted laparoscopic surgery (HALS) procedures and how to report them according to new guidance in the 2024 ICD-10-PCS guidelines.
Fentanyl and other synthetic opioids are the most common drugs involved in overdose deaths in the U.S. Tonya Chandler, RHIT, examines ICD-10-CM reporting for fentanyl use, overdose, symptoms, and dependence through several coding scenarios.
Coders saw extensive code changes and expansion for ICD-10-CM category O35.- in 2023. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG, reviews what coders need to know when reporting fetal conditions affecting the management of the mother.
Kate Siemens, RN, CMSRN, CCDS, conducts an interview with Majed Gharfeh, MD, to offer a physician’s perspective on queries and tips on how coders can receive the best results from querying their providers.
The term “stroke” or cerebrovascular accident (CVA) indicates an interruption in blood flow to the brain. Nancy Reading, RN, CPC, CPC-P , reviews strokes and explains how coders should report them and their treatment in ICD-10-CM and ICD-10-PCS. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
As the COVID-19 public health emergency has ended, audits are likely to pick up steam. To prepare for this increase in audit activity, it’s essential for providers and coders to examine both current and upcoming trends.
Amanda Vincent , Javier Ortiz , and Teresa Brown, RN, CCDS, CDIP, CCS , identify various CMS quality programs, discuss common conditions these programs assess, and highlight their impact on patient safety through examples and coding case studies.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, explains the significance of reporting social determinants of health (SDoH) with examples related to health literacy, environmental factors, and living conditions.
Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS, describes how coding reviews provide an opportunity to conduct a thorough compliance review that not only addresses components of the coding process, but also the integrity of the patient’s record. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Antibiotic resistance occurs when bacteria become resistant to drugs designed to kill them. Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, offers guidance on querying physicians for antibiotic resistance organisms.
Encephalopathy refers to any disease of the brain that alters its function or structure. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG, breaks down documentation requirements and ICD-10-CM coding for toxic, acute, and chronic encephalopathy.
Learn about the challenges faced and collaborative opportunities encountered by one organization when it began the process of improving its observed-over-expected mortality ratio.
Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS, describes how coding reviews provide an opportunity to conduct a thorough compliance review that not only addresses components of the coding process, but also the integrity of the patient’s record.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, explains the significance of reporting social determinants of health (SDoH) with examples related to health literacy, environmental factors, and living conditions.
The term “stroke” or cerebrovascular accident (CVA) indicates an interruption in blood flow to the brain. Nancy Reading, RN, CPC, CPC-P , reviews strokes and explains how coders should report them and their treatment in ICD-10-CM and ICD-10-PCS.