Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director for HCPro, a division of BLR, 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 sepsis query.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, provides this sample operative report for coding a hysterectomy for ICD-9-CM and ICD-10-CM, as well as CPT codes.
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.
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.
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.
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.
This form includes a clarification request for respiratory failure, including sourced definitions. It is intended as a sample only and any diagnostic criteria should meet the approval of your medical staff.
