Physicians are constantly reminded that healthcare is undergoing significant change. October 2015 marked one more landmark change: the shift to ICD-10. Many physicians have worried about the transition and likely dreaded the loss of familiar...Read More »
CMS scours all claims it processes for eligible discharges for the pneumonia readmission measure. Every discharge that meets defined requirements counts regardless of whether the discharge resulted in a readmission. These eligible discharges are then...Read More »
Many clinical documentation improvement (CDI) specialists with clinical backgrounds are encoder dependent, trained to “code” using an encoder and taught to create a working MS-DRG based on grouper software. Many coders also rely on the...Read More »
To understand how to appropriately assign codes for chronic kidney disease (CKD) and acute kidney injury (AKI), instead of just reporting the codes that correspond with each and every note in the record, coders need to take a closer look at the clinical...Read More »
The incidence sepsis cases within the United States has quadrupled while the length of stay of these cases and the mortality has decreased. And Recovery Auditors have denied numerous claims because, at least in part, CDI staff queried to get sepsis DRGs when...Read More »
ICD-10-CM/PCS requires increased specificity in the clinical documentation to support that specificity in coding, says Bonnie S. Cassidy, MPA, FAHIMA, FHIMSS, RHIA, AHIMA-approved ICD-10 trainer, senior director of HIM innovation at Nuance Communications headquartered in...Read More »
After three years’ worth of frustration and postponements ICD-10-CM/PCS implementation seems to have been much ado about nothing (to quote Shakespeare). The October 1, 2015, implementation date has come and nearly a month has passed wherein the United States healthcare system lumbered on pretty...Read More »
I was recently discussing the state of EHRs in regard to the poor quality of the documentation with a colleague who has been a practicing HIM professional for more than 35 years and currently works for a large group of hospitals as the...Read More »
