Q: We recently had a situation where a patient was admitted for syncope workup and all the workups were negative except for incidental findings of AKI. The physician documented “AKI likely 2/2 hypovolemia. Treatment focus is to trend creatinine levels...Read More »
by Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS
Coding reviews provide an opportunity for you to conduct a thorough compliance review that not only addresses other components of the coding process but also the integrity of the patient’s record.Read More »
By Cheryl Ericson, MS, RN, CCDS, CDIP, Stephanie Hawley, RN, BSN, ACM, and Anny Pang Yuen, RHIA, CCS, CCDS, CDIP
A crucial part of building a successful CDI department is making its mission known within the whole organization. Once the mission is established, share it. While each...Read More »
Some words are just fun. Fun to say, fun to spell, fun to use. One of those words, in my opinion, is quiver. Say it out loud. “Quiver, quiver, quiver.” You can’t help but smile.Read More »
Jera Van Damme, BSN, RN, CCDS, is a senior clinical documentation educator at Essentia Health in Duluth, Minnesota, a member of the Minnesota ACDIS Chapter, and a member of the ACDIS Forms & Tools Library Committee.Read More »
The evaluation and management (E/M) section of the Current Procedural Terminology (CPT®) manual is divided into broad categories such as office visits, hospital visits, and consultations. E/M code assignment consists of seven...Read More »
