Q: We have started receiving rejections for ED claims when the service involves removing impacted cerumen. We are reporting CPT® code 69209 (removal impacted cerumen using irrigation/lavage, unilateral) for each ear, and the documentation supports the irrigation/lavage rather than the...Read More »
Editor’s note: Barnett is a CDI specialist at MedPartners HIM in Tampa, Florida. She was one of the 12 member 2017 Conference Committee. For more information regarding the conference committee and to apply for...Read More »
Q: What is the best way to document time spent by physicians performing procedures? The CPT® codes state a vague time amount but the doctors struggle with this.
A: Time is always one of those really fun things, especially with E/M codes, because CPT puts a vague...Read More »
The CDI specialist role is complex and multidisciplinary, suitable for clinically knowledgeable professionals who are proficient in analyzing and interpreting medical record documentation and capable of tracking and trending their CDI program goals...Read More »
The selection of the principal diagnosis is one of the most important steps when coding an inpatient record. The diagnosis reflects the reason the patient sought medical care, and the principal diagnosis can drive reimbursement....Read More »
