Q:The primary physician documented subacute cerebral infarction and I am wondering whether I should code this to a new cerebral vascular accident (CVA) or not since the term “subacute” doesn’t really fall anywhere.
CMS issued new guidance last week aimed at clarifying the so-called “two-midnight rule” finalized in the 2014 IPPS. The rule essentially states that physicians should order an inpatient admission if he/she expects the care...Read More »
Although Recovery Auditors have identified more than a billion dollars in inappropriate payments, CMS needs to do more to improve its oversight of the program, and target potential instances of fraud identified by the program,...Read More »
Inpatient coders are accustomed to assigning a present-on-admission (POA) indicator in ICD-9-CM and they will continue to do so in ICD-10-CM. Although the POA indicators remain the same, ICD-10-CM includes a list of codes that...Read More »
Q:When atelectasis is noted on an ancillary test such as a CT-scan of the abdomen or chest x-ray can nursing documentation of turning, coughing, and deep breathing considered an intervention that qualifies as one of the criteria to meet a secondary diagnosis?...Read More »
Effective January 1, 2014, candidates who apply for the Certified Clinical Documentation Specialist (CCDS) exam must have a minimum of two years of documentation specialist experience in order to qualify. This is a change from current requirements....Read More »