ICD-10-CM and ICD-10-PCS should eventually result in better data capture nationwide. The change means healthcare organizations urgently need to educate providers on the importance of improved patient care documentation. The Winthrop University Hospital clinical documentation improvement (CDI) specialists and HIM team have presently implemented a new query for acute myocardial infarctions to help. The newly created forms incorporate the language necessary to capture documentation within these two new areas of enhanced specificity. The team reviewed the queries' content, structure, design, and use to ensure they would be effective and accepted.
Rebecca A. “Ali” Williams, RN, BSN, CCDS, manager of documentation integrity at Spartanburg Regional Medical Center and Village at Pelham Hospital in Spartanburg, S.C., shared this sample query for a subarachnoid bleed in ICD-10-CM.
Use this crossword puzzle to test how well you can assign ICD-10-CM codes. The clues provide the description of the procedure. The code is the answer, and decimals count as one square.
Use this flow chart to help determine whether process changes are necessary to reach your goal of a 24-hour history and physical turnaround time. Gather baseline data (a good starting sample is 30 medical records) and pull together a team (per- haps consisting of the transcription manager and transcriptionists) to “flow out” the process.
Hyperbaric oxygen therapy (HBO) is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. CMS and other payers currently only reimburse for HBO to treat certain conditions. Gloria Miller, CPC, CPMA, vice president of reimbursement services for Comprehensive Healthcare Solutions, Inc., in Tacoma, Wash., provided these checklists to use to prequalify patients for HBO therapy.
Coders need to know the official definitions for the root operations in ICD-10-PCS in order to build the correct code. Use this match game to test your knowledge of the nuances of ICD-10-PCS root operations.
The HIM team at Cheshire Medical Center/Dartmouth-Hitchcock Keene (N.H.) produces Coding Commentary, a monthly newsletter dedicated to coding and documentation. View a sample of the newsletter and a Q&A with Chris Simons, MS, RHIA, director of HIM and privacy officer at Cheshire. The interview and newsletter originally appeared in the August 2012 issue of Medical Records Briefing.
Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director for HCPro in Danvers, Massachusetts, and ACDIS Advisory Board member Mark LeBlanc, RN, MBA, CCDS, clinical documentation manager at Hennepin (Missouri) County Medical Center, donated this sample ICD-10-CM alcohol dependence query.
