On October 14, we reported that CMS issued a controversial MLN Matters special edition (SE) article which stated that all inpatient admissions needed to have any/all ‘other’ or ‘secondary’ diagnoses documented by the attending physician.
In the spring, AHIMA released its “Guidance for Clinical Documentation Improvement Programs” in the Journal of AHIMA and also published its 41-page Clinical Documentation Improvement Toolkit. The documents offer sample job descriptions, definitions for documentation clarifications...Read More »
CDI specialists need to use all the tools available in their documentation training box to effectively change physician behavior. Educational sessions are helpful, particularly when followed by effective queries targeting the same educational issue. Combine this approach with e-mail newsletters...Read More »
At the September 15, 2010 ICD-9-CM Coordination & Maintenance Committee Meeting, the committee implemented a partial freeze for both ICD-9-CM codes and ICD-10-CM and ICD-10-PCS codes prior to the start of ICD-10 on October 1, 2013.
The partial freeze will occur as follows:...Read More »
Patients who survive sepsis infections face a long battle with cognitive and physical decline, according to research from University of Michigan Health System physicians that will be published in the Journal of the American Medical Association (JAMA) today, Oct. 27. Theodore "Jack"...Read More »
MS-DRG 432 (cirrhosis and alcoholic hepatitis with MCC) is one of many MS-DRGs slated for RAC validation audits by HealthDataInsights and Connolly Healthcare, two of the four RACs nationwide.
RACs may target this particular MS-DRG for a variety of reasons, says...Read More »
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 »