By Laurie L. Prescott, MSN, RN, CCDS, CDIP, CRC, and Sharme Brodie, RN, CCDS
The inpatient prospective payment system (IPPS) requires all facilities to report a present on admission (POA) indicator (or code) for all claims. There is no required time frame as to when a provider...Read More »
My colleague Dr. Douglas Campbell, my senior partner and mentor in all things CDI, dropped into my glass-fronted office the other day with a question. I mention the glass because, as, Dr. Campbell had the foresight to have his glass wall frosted...Read More »
Darla Martin, RHIA, CCS, CCDS, is a clinical program manager at Iodine Software. She is a member of the North Carolina and South Carolina ACDIS local chapters, a member of AHIMA and PAHIMA, and is a volunteer member of the ACDIS Forms & Tools Library Committee.Read More »
Q: I’ve heard that if a condition cannot be identified as POA, it will not keep the criteria for a principal diagnosis and cannot be sequenced as such. I recently had a patient who was admitted for syncope and all the workup was negative, but it’s...Read More »
Richard Pinson, MD, FACP, CCS, is a principal and co-founder of Pinson and Tang, LLC. Dr. Pinson will be presenting on Day 2 of the 2018 ACDIS Symposium: Outpatient CDI. The title of his presentation is “Diabetic complications...Read More »
Although managing accurate principal diagnoses and CC/MCC assignment is always going to be a focus for CDI professionals and coders (along with clarifying general documentation inconsistencies). Clinical validation denials are on the rise, making record...Read More »
I was recently reviewing Coding Clinic, First Quarter 2018, and felt that the question regarding physeal fractures needed more clarification and explanation than was provided in the official answer.
Q: During a final pre-bill coding review, the coding leader identifies a CDI initiated query that does not meet the ACDIS/AHIMA guidelines for a compliant query. But, the physician has already responded to the query with a diagnosis which was then...Read More »
