Verbal conversations with providers regarding reportable conditions and procedures are considered verbal queries. Refresh how they should be memorialized within the record to maintain compliance. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
JoAnn Baker, CCS, CPC, COC , defines sepsis and septic shock, and delves into the emerging initiative to integrate AI into the diagnosis and treatment process.
A study published in the Journal of the American Medical Association found that four popular pretest risk assessment models for evaluating risk of hospital-acquired venous thromboembolism in inpatients did “not perform particularly well.”
Q: A 64-year-old female inpatient has hepatocellular cancer with an orthotropic liver transplant with bile duct obstruction and is immunosuppressed due to drugs. Which ICD-10-CM codes would be reported?
Kathy Dorich, MSN, RN, CCDS, CPHQ , explains two types of DRG reconciliation processes that she has implemented to alleviate conflict between coding and CDI departments.
Our experts answer questions about querying a metabolic encephalopathy diagnosis and documenting the start of mechanical ventilation if a patient is intubated in another ED.
JoAnn Baker, CCS, CPC, COC , defines sepsis and septic shock, and delves into the emerging initiative to integrate AI into the diagnosis and treatment process.
Hamilton Lempert, MD, FACEP, CEDC, reviews the basics of CPT critical care services and addresses common reporting questions, such as services that pass midnight, continuous care, and which clinical tasks count toward critical care.
Make sure staff who handle audit requests understand when a missing signature should—or should not—trigger an automatic denial of your claims or prior authorization requests. Recent guidance from CMS clarifies how auditors should proceed when a medical record lacks a signature.
by Sareem Wani, MD I recently took a personality test and, after answering a series of questions based on various case scenarios, learned that my strengths are in collaboration and education. It took...
Managing chronic conditions requires involvement from many parties, making documentation challenging. Assess how to improve documentation and reimbursement for chronic conditions with tips provided by Arta Kelmendi-Doko, MD, PhD . Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: A patient has acute renal failure due to dehydration, a history of Type 1 diabetes mellitus causing end-stage renal disease, a kidney transplant two years ago, and chronic kidney disease stage 3a, immunosuppressed by their drugs. How would this be reported in ICD-10-CM?
A Journal of the American Medical Association study found that ICD-10-CM influenza codes accurately represented cases of positive diagnoses in pediatric patients, but their sensitivity was modest.
Brandi Hutcheson, RN, MSN, CCM, CCDS, CCA , examines the coding and clinical literature on malnutrition and obesity to see how coders can reconcile these seemingly disparate diagnoses.
Penny Jefferson, MSN, RN, CCDS, CCDS-O, CCS, CDIP, CRC, CHDA, CRCR, CPHQ , and Mercedes K. C. Dullum, MD, FACS, FACC , describe the advantages of creating CDI programs in outpatient settings and how they can decrease gaps in patient care and improve financial management.
