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.
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.
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.
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.
Reviewing a sample of claims for clinical validity and coding accuracy can seem like a daunting task. Kaitlin Loos, RN, BSN, CDI auditor, and Molly Siebert, RHIA, CCDS, CDI specialist, describe their individualized review processes.
The primary purpose of CDI work is to review medical records to increase the accuracy and specificity of provider documentation. Review the primary responsibilities of a CDI specialist including documentation review, querying, and physician education.
Patients are often admitted for acute conditions and experience additional issues affecting their care and treatment plan during the encounter. Ashayla Stephens, MHA, RHIA, CCS , and Audrey Howard, RHIA , describe the process of validating multiple diagnoses documented within the health record. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Physician documentation of heart failure must specify the type and severity of the illness to apply the most accurate code. Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM , breaks down clinical documentation and ICD-10-CM coding for four types of heart failure.
Due to the complex nature of sepsis, some cases require querying the provider prior to assigning ICD-10-CM/PCS codes. Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM , breaks down inpatient coding and querying for sepsis.
One of the biggest components of a leader’s role is to track, trend, and report on the department’s performance. Learn strategies for balancing priorities and time constraints and presenting key performance indicators to leadership.
Computer-assisted coding (CAC) technology analyzes healthcare documentation and selects codes based on specific phrases and terms. Review the pros and cons of using this software to perform inpatient coding and billing functions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
One of the biggest components of a leader’s role is to track, trend, and report on the department’s performance. Key performance indicators can range in complexity depending on the needs of the organization, but all are imperative for proving the success of a CDI or coding program.
Susan Belley, M.Ed., RHIA, CPHQ, and Audrey Howard, RHIA, write that a majority of inpatients during this omicron surge are admitted for reasons other than COVID-19 and are incidentally found to be COVID-19-positive—making this an opportune time to review ICD-10-CM reporting for COVID-19 as a secondary diagnosis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM, says that when reporting sepsis in ICD-10-CM, it’s important that evidence of sepsis is found throughout the body of a patient’s medical record. A clinical validity query may be necessary if the provider confirms the diagnosis of sepsis, but clinical evidence is lacking in the documentation.
Departmental silos are prevalent in the healthcare world and can lead to unvoiced frustrations and counterproductive work. This article reviews how different organizations have various approaches to breaking down these walls.
Jillian Harrington, MHA, CPC, CPC-I, CPC-P, CCS, CCS-P, CEMC, MHP, writes that in order to ensure proper coding, documentation, and reimbursement, it’s great practice to have inpatient coding and CDI teams review querying procedures yearly. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Many physicians are not entirely aware of the denials landscape and their involvement in it is often something they never anticipated. Educating physicians on their role in coding denials is important as it will help ensure proper reimbursement. Part two of this two-part series discusses involving physicians in administrative law judge appeals and monitoring success rates.
Many physicians are not entirely aware of the denials landscape and their involvement in it is often something that they never anticipated. Educating physicians on their role in coding denials is important as it will help ensure proper reimbursement. Part one of this two-part series discusses how to make time for proactive education.
According to Deanne Wilk, BSN, RN, CCDS, CDIP, CCDS-O, CCS, patient safety and quality of care are forerunning concerns for organizations today, and hospitals need to examine how and when they evaluate that quality of care in order to remain ethical and compliant.
Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC, MSHIM, RHIA , writes that one diagnosis in particular that can take extra effort to understand is acute kidney injury (AKI). Frequently reviewing coding and CDI challenges related to AKI will ensure proper coding and reimbursement.
In this article, Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC, MSHIM, RHIA , breaks down acute respiratory distress syndrome (ARDS) and sepsis criteria and reviews documentation and querying for these diagnoses through a case study.
All inpatient coding and CDI professionals, whether new to the field or industry veterans, should be familiar with the American Hospital Association’s Coding Clinic . This article reviews the steps to take and the importance of submitting coding questions.
In this article, Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC, MSHIM, RHIA , breaks down the various definitions and criteria for sepsis and reviews documentation and querying for this diagnosis through a case study.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS, writes that through updated heart failure definitions and clinical criteria, coders and CDI teams now have help to ensure that congestive heart failure is properly documented and denials are avoided.
Hospitals often put significant thought, time, and energy into hiring new team members, and while coding and CDI managers can have the best possible staff, if they don’t feel appreciated, the odds of them staying with the company long term are low.
In this article, we will take a closer look at clinical indicators for acute myocardial infarction, congestive heart failure, and arrythmias. Frequently reviewing clinical indicators for complicated diagnoses such as these will ensure both proper ICD-10-CM reporting and reimbursement.
Howard Rodenberg, MD, MPH, CCDS, writes that it only takes one or two inappropriate queries to a provider for the process to seem burdensome to them. To avoid this scenario, Rodenberg proposes three questions to consider once you’ve decided a query is in order.
It’s not unusual for CDI and inpatient coding teams to cite physician education and engagement as one of their top struggles in the field. In this article, read how the CDI team at Avera Health System turned to their query data to craft a focused education program and meet their physicians on the same page.
Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, reviews how critical thinking is important within the CDI and coding realm in order to enhance review accuracy and query rates and to help loosen reliance on technological tools such as encoders.
Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC, MSHIM, RHIA, writes that CDI professionals and inpatient coders need to pay attention to the definitions and clinical indicators of acute kidney injury (AKI) to ensure proper ICD-10-CM reporting and reimbursement.
Dawn Valdez, RN, LNC, CDIP, CCDS, says that the clinical indicators used to validate sepsis can also have other possible etiologies that could be equally responsible for the clinical indicators that are present—these are known as competing diagnoses.
Howard Rodenberg, MD, MPH, CCDS, and Lynn Shay, CPHQ , say that making sense of varying COVID-19 case-mix index metrics is an important endeavor that will sometimes require a bit of DIY. In this article, they explain how they were able to unscramble their departments’ COVID-19 case-mix index data.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS, writes that organizations that aren’t reviewing all in-hospital mortality cases are missing some tremendous opportunities to improve reimbursement and documentation.
Pediatric record reviews require a different skill set than those in the traditional adult acute care space. Often, those reviewing these specialized charts are islands within their overall CDI or coding department, acting as the sole pediatric chart reviewer. This article sheds light on how some have perfected these reviews within their department.
Howard Rodenberg, MD, MPH, CCDS , describes how internal reviews can be used to identify repeated coding errors and prevent payment penalties due to Patient Safety Indicators (PSI) and hospital-acquired conditions (HAC).
Joe Rivet, Esq, CCS-P, CPC, CEMC, CHC, CCEP, CHRC, CHPC, CICA, CPMA, CAC, CACO , summarizes findings from recent Office of Inspector General audits that highlight improper billing of high-level inpatient stays. He also outlines steps hospitals can take to prevent billing errors due to upcoding.
A recent Office of Inspector General audit estimates that Medicare improperly paid inpatient hospitals $267 million over a two-year period for transfer services incorrectly billed as discharges. Judith Kares, JD , analyzes documentation and billing rules for acute and post-acute transfers.
The evolution of the role of clinical documentation integrity (CDI) specialists and their impact on coders has changed the landscape of inpatient coding departments. Learn about how to effectively collaborate with CDI professionals when conducting physician queries.
Review quality reporting metrics such as length of stay and mortality indexes that you can use to assess patient outcomes and improve revenue cycle processes.
In part one of this two-part series, Allen Frady, RN, BSN, CCS, CRC, CCDS, gives tips to CDI and coding teams on how to help improve healthcare quality scores by reviewing CMS star rating calculations, department challenges, physician education, and more.
It’s important for inpatient coders to frequently review hospital-acquired conditions (HAC) and present on admission (POA) indicators and the rules governing their assignment in order to ensure proper reimbursement. Part one of a two-part series will review POA indicators in particular.
Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC, MSHIM, RHIA, says with recent audit activity and the Office of Inspector General’s continued scrutiny of malnutrition diagnoses, it’s important to dig into the coding and documentation requirements for this tricky diagnosis, particularly in the case of COVID-19 patients.
In this article, Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC, RHIA, says inpatient coding professionals need to look for signs and symptoms supportive of sepsis in order to report the most accurate codes, which is why staying up to date on the ever-changing clinical criteria for sepsis is so important.