This 61-page orthopedic superbill includes ICD-10 and CPT codes and descriptions for a variety of orthopedic services. Roberta Bosank-Cera of Hospitals for Special Surgery, New York, NY, submitted the superbill to the Association of Clinical Documentation Improvement Specialists.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, provided this documentation and coding example for reporting fetal status for ICD-9-CM and ICD-10-CM.
This policy establishes guidelines for inpatient physician queries. It is provided by Donald A. Butler, Manager of Clinical Documentation at Vidant Medical Center in Greenville NC. It was originally published on the Association for Clinical Documentation Improvement Specialists website.
Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director at HCPro, a division of BLR, in Danvers, Massachusetts, provided this sample multiple-choice query for chest pain.
These sample malnutrition queries were donated by Cheryl Ericson, MS, RN, CCDS, CDIP, 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 (Mo.) County Medical Center, who spoke during the June 10 webinar “Physician Queries: Ensure Effective, Compliant, Regulatory-Based Clarifications.” The queries also appear on the ACDIS website.
These sample ICD-10-CM queries address establishing the relationship between conditions in ICD-10 t. These queries are adapted fromThe CDI Specialist’s Guide to ICD-10, created and donated by Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA approved ICD-10-CM/PCS trainer, CDI education director at HCPro, Inc., in Danvers, Mass.
This query form is a request for documentation clarification of pathology findings. It was submitted by Paul Evans, RHIA, CCS, CCS-P, supervisor of clinical documentation integrity at Sutter Health in San Francisco. It originally appeared on the Association for Clinical Documentation Specialists website.
The Winthrop University Hospital clinical documentation improvement (CDI) specialists and HIM team implemented a new query for cerebral infarctions in preparation for the transition to ICD-10. The newly created form incorporates the language necessary to capture documentation within this new area of enhanced specificity.
