Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS, review the recently published “Global Leadership Initiative on Malnutrition (GLIM) Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community” and help coders apply this criteria in ICD-10-CM.
Sarah Humbert, RHIA, and Catrena Smith, CCS, CCS-P, CPCO, CPC, CIC, CPC-I, CRC, CHTS-PW, explore three scenarios for onboarding new inpatient coders and provide valuable advice to prepare them for success.
As the task of query creation is becoming more prevalent in coding departments, reviewing essential query requirements is a must for all inpatient coders. This article covers these essential requirements including the growing adoption of electronic medical records, when to query, and pointers for submitting queries to physicians. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Data in CDI reports should demonstrate the depth of work performed as well as productivity elements. I want to share my experience of personalizing data fields in our CDI software to fully demonstrate our CDI team’s impact beyond moving the MS-DRG.
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.
For patients who suffer from frequent symptoms of gastroesophageal reflux disease (GERD), the provider may have to increase to prescription strength medications and possibly consider surgical intervention for severe cases. In this article, Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, HCS-D, reviews ICD-10-CM/PCS coding for these GERD diagnoses and procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
When pneumonia documentation is questioned, CDI specialists or coders should always query the provider. But reviewing the following clinical elements involving aspiration and pneumonias with your physician staff may help improve the documentation of complex pneumonias and avoid adverse determinations by external reviewers.
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.
Like it or not, provider documentation is the foundation for everything done in medicine. Without it, nothing is accomplished. As healthcare reform progresses (and hospital reimbursement shrinks), the need for excellent provider documentation only increases.
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.
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.
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.
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.
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.