Clinical quality measures are tools used by healthcare professionals to measure or quantify processes and outcomes. Audrey Howard, RHIA, and Susan Belley, RHIA, CPHQ, describe documentation elements that affect quality metrics and how to incorporate them into an audit workflow.
The principal diagnosis is key to prioritizing subsequent reviews, identifying potential quality measure inclusion, and pinpointing query opportunities. Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , breaks down guidance for selecting the principal diagnosis.
The terms “admission” and “observation” are often confused. Dawn Valdez, RN, LNC, CCDS, CDIP , distinguishes between these terms and evaluates ICD-10-CM coding for patients who begin in observation and are later admitted to the hospital for more intensive care.
Lena Wilson, MHI, RHIA, CCS, CCDS , takes a deep dive into the CDI/coding reconciliation process and outlines tips that coders and CDI professionals can apply to improve this process.
Pregnancy causes changes to the immune system that increase the risk of infection and sepsis during pregnancy, labor, and the puerperium. Sarah Nehring, BS, RHIT, CCS, CCDS , analyzes ICD-10-CM documentation and coding for sepsis after childbirth.
Social determinants of health ICD-10-CM codes have become more of a hot topic in the CDI world over the past few years. Review guidance for reporting personal circumstances such as income, wealth, and education that impact health and wellbeing.
Respiratory failure occurs when the body is unable to provide oxygen to or remove carbon dioxide from the body. Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , breaks down documentation and ICD-10-CM coding for acute and chronic respiratory failure.
A properly calibrated audit tool is key to uncovering educational opportunities for coding and CDI professionals. Dawn Valdez, RN, LNC, CDIP, CCDS, outlines questions for determining an audit focus and for querying providers when documentation is insufficient to support medical necessity.
Audits are crucial to helping CDI and coding teams stay up to date with the fast pace of medicine and continual changes to coding guidelines. Dawn Valdez, RN, LNC, CDIP, CCDS , writes about best practices for auditing and application of audit findings .
Debridement is used to treat serious or chronic wounds that do not heal with standard treatment. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG , describes five types of debridement and how to report these procedures in ICD-10-PCS.
Social determinants of health such as economic stability and access to education significantly impacting health outcomes. Kim Conner, BSN, RN, CCDS, CCDS-O , outlines potentially confusing ICD-10-CM guidelines and documentation challenges that complicate coding for social determinants.
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.
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.
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.
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.
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.
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.