R.A. Bobrowski, MD, and Lori-Lynne A. Webb,CPC, CCS-P, CCP, CHDA, COBGC, provide operative report examples to distinguish the correct degree of laceration to report during deliveries, according to CPT® and American Congress of Obstetricians and Gynecologists guidelines.
Karen Bridgeman, MSN, RN, clinical documentation integrity specialist at the Medical University of South Carolina in Charleston, donated these case examples and sample queries for pediatric hypoxic ischemic encephalopathy, following her ACDIS National Conference presentation "Leap Frog to Pediatrics: Implementing a Successful Pediatric CDI Program.” They originally appeared on the ACDIS website.
This sample query regarding establishing cause and effect relationships between diagnoses was donated by Paul Evans, RHIA, CCS, CCS-P, CCDS, Manager, Regional Clinical Documentation & Coding Integrity, at SutterHealth in San Francisco, Calif. It was originally published on the Association for Clinical Documentation Improvement Specialists website.
When coding guidelines are murky and open for interpretation, coders can sometimes feel as though they're pinned between a rock and a hard place. Discussing the gray areas of coding during a coding roundtable not only helps relieve this tension, but it also helps to establish policies that ensure consistency and continuity. Use this sample charter to build your own coding roundtable.
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 burn query.
Inpatient coders can struggle with documentation requirements for wound care procedures. Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, and Robert S. Gold, MD, provided this sample wound care procedure note during the HCPro audio conference Inpatient Wound Care Coding: Clinical Information and Documentation Strategies.
Before billing an outpatient claim with Condition Code 44, coders need to verify certain information. Deborah K. Hale, CCS, CCDS, president of Administrative Consultant Service, LLC, in Shawnee, Okla, created this checklist of information needed before using Condition Code 44.
>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 respiratory failure query.
Karen Bridgeman, MSN, RN, clinical documentation integrity specialist at the Medical University of South Carolina in Charleston, donated this case example and sample query for pediatric bronchopulmonary dysplasia, following her ACDIS National Conference presentation "Leap Frog to Pediatrics: Implementing a Successful Pediatric CDI Program.” They originally appeared on the ACDIS website.
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, provided this query to use when a physician admits a patient with a history of alcoholism but provides no diagnosis.
