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 fracture query.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, provided these examples for anemia documentation for OB/GYN patients and the questions coders to ask in order to report the correct diagnosis.
Deborah K. Hale, CCS, CCDS, president of Administrative Consultant Service, LLC, in Shawnee, Okla, provided this pocket card to use when determining whether a patient should be admitted.
This attached pneumonia documentation decision tree, courtesy of Gina Spatafore of Waterbury Hospital, is designed to help physicians document pneumonia, unspecified to the highest degree of specificity. It was originally published on the Association for Clinical Documentation Improvement Specialists website.
Deborah K. Hale, CCS, CCDS, president of Administrative Consultant Service, LLC, in Shawnee, Okla, provided this pocket card to use when determining whether a patient should be placed in observation.
Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, Florida, created this 15-question quiz on respiratory codes and conventions in ICD-10-CM.
Reinforce what your coders are learning as they prepare for ICD-10 with some fun games related to anatomy and physiology and ICD-10 coding subjects. Check out this week’s platinum offering, which includes crosswords, word searches, and matching games to help coders stay engaged.
The attached PDF reviews documentation and coding needs for complications and establishes policies and procedures for coders and CDI professionals to follow. Created by Paul Evans, RHIA, CCS, CCS-P, CCDS, the document provides complication definitions, explains when queries should be issued, and explores specific documentation concerns regarding conditions such as incidental serosal tear and postoperative atrial fibrillation.
This form contains a proposal for mandatory physician education regarding facility CDI practices. Created by Rebecca "Ali" Williams, RN, BSN, CCDS, this document can be adapted and brought forward to your facility's medical staff director or your program director to foster the ongoing training of incoming physicians.
