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.
Sharme Brodie, RN, CCDS, reviews recent guidance published in Coding Clinic , Third Quarter 2018, including advice on diabetes, acute myocardial infarctions (AMI), pressure ulcers, and more.
A new risk model provides a simple way to determine whether acute myocardial infarction (AMI) patients are at a high risk for hospital readmissions, says a study published in the Journal of the American Heart Association.
Q: Can an ICD-10-CM body mass index (BMI) code be used as a standalone code? If not, what documentation should we look for to justify the use of a BMI code?
Crystal R. Stalter, CPC, CCS-P, CDIP, says that there is still confusion around documenting patient stays to show quality, especially in the inpatient realm. Is it really as simple as documenting conditions to their fullest specificity or does it involve a more complex approach?
Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, writes that understanding spinal anatomy, the reporting of detailed spinal diagnoses, and the selection of applicable procedure codes can ensure that these complicated claims are reimbursed correctly and in compliance with coding guidelines. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Adriane Martin, DO, FACOS, CCDS , reviews some of the ICD-10-CM/PCS code and CC/MCC updates that made the final cut in the fiscal year 2019 IPPS final rule.
Q: We have a patient admitted with a history of chronic heart failure (CHF) and end-stage renal disease (ESRD) who was admitted with volume overload due to acute kidney injury and dialysis noncompliance. How should we report this in ICD-10-CM?
The rate of most hospital-acquired conditions (HAC) continued to decline from 2014 to 2016, according to the latest national scorecard released by the Agency for Healthcare Research and Quality.
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.
Acute heart failure patients in an emergency department's clinical pathway program had a 13.1% lower readmission rate, according to a report published in the American Journal of Emergency Medicine.
Adriane Martin, DO, FACOS, CCDS, reviews Coding Clinic guidance published in the first and second quarters of this year as it pertains to coding guidelines, severity of illness, and MS-DRG assignment for the inpatient setting.
Q: We recently had a patient admitted for syncope workup. The workups were negative except for incidental findings of acute kidney injury (AKI). The physician documented “AKI likely 2/2 hypovolemia. Treatment focus is to trend creatinine levels and hydration.” Would the AKI or hypovolemia be sequenced as the principal diagnosis?
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.
Creating a query and knowing when to query can be complicated, and there are a number of continued training tactics that prove successful for the coder when trying to improve upon physician query practices. This article looks at a few of the official sources that offer query guidance for coders. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Inpatient coding audits need to be tailored to the type of record being reviewed, the time it may take to complete the audit, and any compliance-related issues that may crop up. This article focuses on how coding managers can streamline these aspects to ensure a successful audit. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Early readmissions were more likely to be preventable and amenable to hospital-based interventions, according to a recent study published in the Annals of Internal Medicine.
Allen Frady, RN-BSN, CCDS, CCS, CRC, says that defending code assignment against denials requires more than reviewing the denial to determine if the condition was coded and reported according to the coding guidelines; it requires an understanding of payer requirements as well.
Q: Our team is having a hard time determining a principal diagnosis for a patient with a history of stage 5 chronic kidney disease (CKD) who is receiving chronic hemodialysis and is in acute renal failure (ARF) with volume overload. Which ICD-10-CM code should be the principal diagnosis?
