Forms

Paula Lewis-Patterson, BSN, MSN, NEA-BC, the clinical administrative director of the ambulatory treatment center at The University of Texas MD Anderson Cancer Center in Houston, provided these and other examples of good and poor documentation for infusions as part of HCPro's audio conference, 2012 Injections and Infusions: CPT Changes, Nursing Documentation Requirements, and Billing Process Review.
 

This form highlights the required documentation necessary for common interventional radiology procedures, including catheterizations, imaging guidance, and therapeutic interventions. Stacie L. Buck, RHIA, CCS-P, RCC, CIC, of RadRX.com created this form.

This query form is a request for documentation clarification of HIV Status. It was submitted by Paul Evans, RHIA, CCS, CCS-P, supervisor of clinical documentation integrity at Sutter Health in San Francisco. It was originally posted on the Association of Clinical Documentation Improvement Specialists website.

These documentation examples from Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, show the type of information providers will need to note in order for coders to accurately apply BMI codes in both ICD-9-CM and ICD-10-CM.

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.

This form represents one example of a possible request for diagnostic clarification/confirmation of diagnosis donated by Paul Evans, RHIA, CCS, CCS-P, CCDS.

>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.

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.

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.