Clinical documentation, Hospital inpatient, Training
This infographic provides coders with guidelines for properly selecting a principal diagnosis when one is not clearly established, which can help promote consistency, reduce the risk of coding errors, and enhance overall coding accuracy.
Coders can use this infographic to access a collection of reliable, up-to-date ICD-11 training references and resources, allowing them to navigate the complexities of the new coding standards ahead of the change. This information was taken from the HCPro webinar “ICD-11: Change is Coming,” presented by Michelle Badore, a global clinical and nosology content manager at Solventum, and Kaycie LeSage, MSHCM, RHIA, CCS, CDIP, CPC, the domestic clinical nosology manager at Solventum.
Anatomy and terminology, Hospital inpatient, Training
This slideshow serves as an interactive digital flashcard tool designed to aid in learning and reviewing ICD-10-PCS operation definitions. Each slide features the definition, explanation, and examples provided by CMS that are essential for understanding the complexities of the ICD-10-PCS system. Users can review definitions at their own pace, making it suitable for both beginners and experienced coders, or coders in group trainings can use this to discuss and quiz each other on specific operations. Ultimately, this slideshow is an invaluable resource for inpatient coders aiming to sharpen their skills and improve coding accuracy through effective and engaging study methods.
The root operations in the following slides fall into one of the following procedure categories:
Procedures that involve only examination of body parts/regions
Procedures that alter the diameter/route of a tubular body part
Procedures that always involve devices
Procedures that define other repairs
Procedures that define other objectives
We recommend downloading the ZIP file to experience the full effect of the slideshow, but a PDF version is also available for your convenience, offering easy access and quick viewing without the need for additional software.
Anatomy and terminology, Hospital inpatient, Training
This slideshow serves as an interactive digital flashcard tool designed to aid in learning and reviewing ICD-10-PCS operation definitions. Each slide features the definition, explanation, and examples provided by CMS that are essential for understanding the complexities of the ICD-10-PCS system. Users can review definitions at their own pace, making it suitable for both beginners and experienced coders, or coders in group trainings can use this to discuss and quiz each other on specific operations. Ultimately, this slideshow is an invaluable resource for inpatient coders aiming to sharpen their skills and improve coding accuracy through effective and engaging study methods.
The root operations in the following slides fall into one of the following procedure categories:
Procedures that take out some or all of a body part
Procedures that put in/put back or move some or all of a body part
Procedures that take out or eliminate solid matter, fluids, or gases from a body part
Procedures involving cutting or separation only
We recommend downloading the ZIP file to experience the full effect of the slideshow, but a PDF version is also available for your convenience, offering easy access and quick viewing without the need for additional software.
Clinical documentation, Hospital inpatient, Training
Applying diagnostic criteria is a significant challenge in the pediatric population. The process is not "one size fits all" given consideration must be made for unique circumstances, including prematurity adjustment for age, congenital conditions, and developmental stage, all of which may impact the patient’s presentation and treatment plan. Due to these varying factors, both care providers and those reviewing for clinical validation require strong clinical judgment and critical thinking skills.
This white paper, published jointly by the Association of Clinical Documentation Integrity Specialists (ACDIS) and the American College of Physician Advisors (ACPA), aims to provide direction and advice in the development of institutional definitions for common, critical pediatric conditions, or to assist organizations in validating and refining their existing institutional definitions. Though written for an audience of CDI professionals, this paper is also valuable for coders, as it can enhance their understanding of complex clinical concepts and the nuances of reporting pediatric respiratory conditions. Additionally, a solid grasp of these definitions enables coders to better collaborate with CDI teams, facilitating more precise documentation and supporting accurate coding for improved reimbursement rates.
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.
