Q: Recently, a consultant suggested that if we asked the physician to clarify systolic/diastolic on a query form for congestive heart failure (CHF) it might be construed as leading the physician if there had been no previous mention of...Read More »
A recent MLN Matters article has changed the official coding guidelines to define what documentation can be used for assigning secondary diagnoses, leaving some CDI specialists worried that it provides RACs with the ability to invalidate any diagnoses not specifically documented by the...Read More »
Kaiser Permanente recently donated its electronic database of medical terminology to the National Library of Medicine and the International Healthcare Terminology Standards Development Organization, which oversees the current international standard medical terminology dictionary. Kaiser’s...Read More »
When it comes to tracking CDI program data, many facilities fall back on the information provided by their consultants,. But other CDI programs often rely on homegrown data systems. Mary Cooper, EVP, of ChartWise Medical Systems, Inc., in Wakefield, RI, suggests a few items to consider for those...Read More »
I often wondered how the ICD-9-CM code set would translate to ICD-10-CM/PCS in regards to MS-DRGs. I couldn’t fathom that along with the costly transition to a new code set, CMS would “double whammy” us by implementing a system...Read More »
Prior to implementing an electronic query application from Meta Health Technology in 2010, the query process at Memorial Hermann was completely manual and extremely time-consuming. To submit a post-discharge query, the coder created a Word document...Read More »
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 »
