Clinical documentation, Health information management, Hospital inpatient
The following is a tip sheet written by the 2024–2025 ACDIS Physician Advisor Committee. Although originally designed for both new and experienced physician advisors, this resource offers foundational information on clinical validation that coders should be aware of.
Auditing and monitoring, Health information management, Hospital inpatient
Coders can use these reference sheets for understanding the importance of quality metrics and the implications of them for all coding professionals. This resource was taken from the HCPro webinar “Managing the Maze: The Impact of Public Quality Metrics on Coding Best Practices”, presented by Kim Conner, BSN, CCDS, CCDS-O, a senior CDI consultant and denials program manager for Enjoin.
Clinical documentation, Health information management, Hospital inpatient
The following is a tip sheet written by the 2024–2025 ACDIS Physician Advisor Committee. Although originally designed for both new and experienced physician advisors, this resource offers foundational information on patient safety indicators that coders should be aware of.
Health information management, Hospital inpatient, Hospital outpatient, Training
Join speakers Michelle Badore and Kaycie LeSage, MSHCM, RHIA, CCS, CDIP, CPC, as they discuss key ICD-11 updates, implementation opportunities, and tips on how to seamlessly transition to this new coding standard.
Clinical documentation, Health information management, Training
Download this organized graphic of AHIMA’s Standards of Ethical Coding to help support yourself as you assign and sequence codes correctly and in a compliant fashion.
Health information management, Hospital inpatient, Physician queries
The following sample policy regarding query escalation and resolution addresses the specific timing expectations for query responses, how coders should communicate with CDI staff and physician advisors, and what circumstances might warrant raising an unanswered query to the attention of a CDI or HIM manager, physician advisor, or higher-level administrator.
Clinical documentation, Health information management, Hospital outpatient, Questions and answers
This expanded Q&A covers CPT documentation requirements for hypothenar fat pad creation. Lynn Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, an independent medical coding education consultant, answered this question.
Health information management, Hospital inpatient, Hospital outpatient
Use this Antibiotic Efficacy Table to aid in identification of antibiotics by brand name and their effectiveness against gram-negative and gram-positive bacteria.
Auditing and monitoring, Health information management, Hospital outpatient, Physician practice, Training
Reporting discussion of management or test interpretation
Count discussions that meet the E/M definition. A “discussion of management or test interpretation” can earn a moderate or high score under the data review element of an E/M office visit. But before you give the billing practitioner credit for a discussion, make sure the documentation shows that it met the definition of a discussion.
Use the illustrated guide on discussions to train staff.
Health information management, Hospital outpatient, Training
Coders should make sure their physicians and qualified healthcare professionals (QHP) are ready for the crucial role in reporting HCPCS Level II code G0136 (administration of a standardized, evidence-based social determinants of health [SDOH] risk assessment tool, 5-15 minutes, not more often than every 6 months).
While practices can perform a SDOH assessment for all of its patients, members of the medical team will take the lead in identifying patients who meet Medicare’s requirements for the billable service.
Share the following illustration with providers to help them negotiate Medicare’s rules. This tool was originally published on Part B News.
