This sample was provided by Laurie Baker, MSN, RN, CCDS, clinical documentation specialist at Memorial Hospital and Health Care Center in Jasper, Indiana. It was originally posted on ACDIS.org.
This sample was reviewed and approved by the ACDIS Resource Library Committee in 2023. The committee recommends that, should you choose to use this sample, you adapt it to your particular programmatic needs, policies, and procedures.
Clinical documentation, Hospital inpatient, Training
This sample was provided by Laurie Baker, MSN, RN, CCDS, clinical documentation specialist at Memorial Hospital and Health Care Center in Jasper, Indiana. It was originally posted on ACDIS.org.
This sample was reviewed and approved by the ACDIS Resource Library Committee in 2023. The committee recommends that, should you choose to use this sample, you adapt it to your particular programmatic needs, policies, and procedures.
Use this decision tree to illustrate Medicare’s rules for coding prolonged E/M services. Medicare created codes and rules for prolonged services performed by a physician or qualified healthcare professional (QHP) because it disagrees with portions of the CPT guidelines.
DecisionHealth, the publisher of Part B News, has revised its tool for office/other outpatient E/M visits (99202-99215) to include encounters performed in the inpatient or observation (99221-99223 and 99231-99236), emergency department (99281-99285), nursing facility (99304-99310) and home or residence (99341-99350) settings and consults (99242-99245 and 99252-99255).
Anatomy and terminology, Clinical documentation, Hospital inpatient
This sample was provided by Trey La Charité, MD, FACP, SFHM, CCS, CCDS, a hospitalist at the University of Tennessee Medical Center (UTMC) at Knoxville, a clinical assistant professor with the department of internal medicine, and the medical director of UTMC’s CDI, coding, and revenue auditor response programs.
This resource, written by Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, presents a clinical coding scenario and information regarding codes for maternal care for a suspected chromosomal abnormality in the fetus from the 2023 ICD-10-CM code set.
