Just because physicians may document the term excisional debridement it doesn’t mean that coders can automatically code the procedure, said Robert S. Gold, MD, CEO of DCBA, Inc. in Atlanta, during the August 5 audio conference “...Read More »
Realizing that the go-live date won’t change, some facilities already have organization-wide ICD-10 implementation strategies in place. If your CDI program hasn’t yet been involved in ICD-10 discussions or if your facility hasn’t starting the planning process yet, consider incorporating elements...Read More »
By Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS
I recently received a fortune cookie from a colleague. After reading the fortune several times, I realized the hidden message certainly has direct relevance to CDI efforts toward affecting overall change in patterns of...Read More »
Q: Whenever we get a trauma patient, it’s either very easy to get to the multiple significant trauma (MST) major diagnostic category (MDC), or it becomes a real challenge, especially taking into account the rules pertaining to two body sites...Read More »
Operative reports can be a gold mine of information, far surpassing often vague or generalized progress notes, but sometimes this resource is left completely untapped, says Lynne Spryszak, RN,CPC-A, CCDS. Coders know they should review the complete operative report before coding...Read More »
Recent approval of a RAC issue for inpatient hospital claims review has initiated uncertainty and places an onus on providers to lean on CMS guidance and policy manuals. The issue, “inpatient admissions without a physician’s inpatient admit order,” can be referenced in the Medicare Claims...Read More »
In March 2008, the National Kidney Foundation sent a letter to the National Centers for Health Statistics and asked that the term “acute kidney injury” (AKI) be an optional phrase for assigning...Read More »
Retaining written, templated, and verbal queries in document form is necessary to ensure CDI compliance. In the current climate of regulatory agencies (e.g., recovery audit contractors and Medicare administrative contractors), it’s a good practice to maintain queries as part of the permanent...Read More »
