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.
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.
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.
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.
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.
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.
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.
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.
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.
