The benefits outweigh the difficulties when it comes to retrospective reviews. How do you get started with this new venture? Like many aspects of CDI, there are many ways to approach the problem. This article details these approaches, including how to enhance coder and CDI collaboration for these reviews.
Not many clinical conditions cause more consternation for inpatient coders and CDI specialists than acute and chronic respiratory failure. In this article, William E. Haik, MD, FCCP, CDIP, details acute and chronic respiratory failure and the critical elements in the health record that validate their reporting.
CDI professionals can improve documentation and data scores via a mortality review process. This article discusses the various types of mortality reviews and publicly reported data and gives tips on how to implement a successful mortality review process.
Julian Everett, BSN, RN, CDIP, details her experience reviewing pediatric mortality cases for the first time and gives tips on how the different revenue cycle departments can work together to improve their processes and outcomes.
Training new inpatient coders and CDI staff is a big job that often takes several months to conclude, but the end of orientation doesn’t mean that staff members never have to undergo education ever again. As most are keenly aware, the ground is always moving under our feet. From new regulations, to coding guideline changes, to new clinical definitions, education never truly ends.
The mechanics of the concurrent coding process can cause headaches for both CDI and coding professionals. Plus, one could argue that CDI’s presence itself limits the number of necessary post-discharge clarifications without the process of concurrent inpatient coding. This article reviews ways that CDI programs can get involved with this process and work collaboratively with coders.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS, writes that by reviewing common electronic health record (EHR) challenges, a CDI program can formulate appropriate mitigation strategies to minimize potential negatives of the system.
Cheryl Manchenton, RN, BSN, CCDS , details the recent updates to patient safety indicator (PSI) 90 and says that these changes are the reason why it’s more important than ever to ensure that PSI metrics are complete and accurate.
Chris Simons, MS, RHIA , outlines tasks that generally fall within the CDI department’s realm and writes that to ensure that inpatient CDI specialists can thoroughly complete these tasks, they must have strong clinical skills and a working knowledge of ICD-10-CM and MS-DRG assignment. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Cesar M. Limjoco, MD, writes that although different literature has become available on principal diagnosis selection through the years, questions and disputes keep popping up. In this article, he revisits the issue and provides additional insight to code selection for conditions such as acute respiratory failure and congestive heart failure.
William E. Haik, MD, FCCP, CDIP, writes that complex pneumonias can segregate to a higher-weighted MS-DRG than other pneumonia types, so reviewing clinical elements with your physician staff may help improve documentation and avoid adverse determinations by external reviewers for these conditions.
Cathy Farraher, RN, BSN, MBA, CCCM, CCDS , details the basics of the All Patient Refined Diagnosis Related Groups (APR-DRG), the system developed to allow for a more specific analysis of outcomes in the non-Medicare population, and shows coders and CDI teams how to better capture quality metrics through documentation.
Amy Sanderson, MD, says that the term “dysphagia” has many synonyms used by providers in medical documentation. However, not all of these symptoms are able to describe the diagnosis with enough specificity so that it can be translated into its corresponding code assignment.
In many cases, knowing when to query is simple, but the more challenging cases contain clues that require additional interpretation. Drew Siegel, MD, CCDS, takes a look at a few of the more interesting and often undocumented diagnoses, including respiratory failure and acute kidney injury, and points out the diagnostic clues to form a compliant query.
Just like their inpatient acute care counterparts, inpatient psychiatric facilities use ICD-10-CM codes, but their payment structure, documentation requirements, prevalent clinical conditions, and additional documentation requirements needing capture are vastly different.
Allen Frady, RN-BSN, CCDS, CCS, CRC, writes about guidance related to documenting acute respiratory insufficiency and gives tips to coders and CDI teams on what to do when the conditions are over-documented postoperatively.