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.
Join expert Kimberly Cunningham, CCS, CPC, CCDS-O, for this 60-minute webinar as she discusses clinical documentation and ICD-10-CM coding for SDoH. Cunningham will review the social and financial impact of capturing SDoH, as well as their impact on quality programs, and describe how these factors are reported in ICD-10-CM. She will also outline considerations for documentation review and describe CMS initiatives aimed at increasing SDoH screening.
Auditing and monitoring, Clinical documentation, Health information management, Hospital inpatient, Hospital outpatient, Physician queries
Guidelines for Achieving a Compliant Query Practice was produced through the joint effort of the ACDIS and AHIMA. Both associations collaborated on the creation of this practice brief and approved its contents, and as such it represents the recommended industry standard for provider queries.
This practice brief supersedes one published in 2019 and all previous versions. This resource was originally published on ACDIS.org.
