Clinical documentation, Health information management, Hospital inpatient
The following is a tip sheet written by the 2024–2025 ACDIS Physician Advisor Committee. Although originally designed for both new and experienced physician advisors, this resource offers foundational information on clinical validation that coders should be aware of.
Clinical documentation, Health information management, Hospital inpatient
The following is a tip sheet written by the 2024–2025 ACDIS Physician Advisor Committee. Although originally designed for both new and experienced physician advisors, this resource offers foundational information on patient safety indicators that coders should be aware of.
Anatomy and terminology, Clinical documentation, Hospital inpatient
The following is a tip sheet written by the 2024–2025 ACDIS Physician Advisor Committee. Although originally designed for both new and experienced physician advisors, this resource offers foundational information on mortality that coders should be aware of.
Clinical documentation, Hospital inpatient, Training
Applying diagnostic criteria is a significant challenge in the pediatric population. The process is not "one size fits all" given consideration must be made for unique circumstances, including prematurity adjustment for age, congenital conditions, and developmental stage, all of which may impact the patient’s presentation and treatment plan. Due to these varying factors, both care providers and those reviewing for clinical validation require strong clinical judgment and critical thinking skills.
This white paper, published jointly by the Association of Clinical Documentation Integrity Specialists (ACDIS) and the American College of Physician Advisors (ACPA), aims to provide direction and advice in the development of institutional definitions for common, critical pediatric conditions, or to assist organizations in validating and refining their existing institutional definitions. Though written for an audience of CDI professionals, this paper is also valuable for coders, as it can enhance their understanding of complex clinical concepts and the nuances of reporting pediatric respiratory conditions. Additionally, a solid grasp of these definitions enables coders to better collaborate with CDI teams, facilitating more precise documentation and supporting accurate coding for improved reimbursement rates.
Anatomy and terminology, Hospital inpatient, Training
This case study was taken from the webinar “2024 ICD-10-CM/PCS Coding: Spinal Diagnoses and Procedures,” presented by Adrienne Commeree, RHIA, CPC, CPMA, CCS, CEMC, CPIP. Commeree is an HIM professor at Tacoma Community College in Tacoma, Washington.
Auditing and monitoring, Clinical documentation, Health information management, Hospital inpatient, Hospital outpatient, Physician queries
Guidelines for Achieving a Compliant Query Practice was produced through the joint effort of the ACDIS and AHIMA. Both associations collaborated on the creation of this practice brief and approved its contents, and as such it represents the recommended industry standard for provider queries.
This practice brief supersedes one published in 2019 and all previous versions. This resource was originally published on ACDIS.org.
Auditing and monitoring, Hospital outpatient, Physician practice, Training
As a coder, have you been wondering what you should do if you hit an NCCI or medically unlikely edit? This infographic will help you learn to manage the edit process, master modifiers to use to bypass edits, and make sense of all of the acronyms used in conjunction with edits.
This ACDIS white paper is presented by Sharme Brodie, RN, CCDS, and discusses the 2017 ICD-10-CM coding guideline recommendations, and important changes that inpatient coders and CDI teams need to note.
Health information management, Hospital outpatient, Physician practice
Read the operative report submitted by Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, and consider the CPT and ICD-10-CM codes you would assign.
