Those who’ve been in CDI long enough remember the days of colored paper queries slipped into charts. Often, those queries would get lost in the literal shuffle, or simply go unanswered and ignored with no concrete way of tracking the query.
Then, electronic health records (EHR) came on...Read More »
By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS
When CMS told the American Medical Association (AMA) physicians could have a one-year grace period to become comfortable with ICD-10-CM/PCS coding systems, they made a bad decision. The agreement allowed providers to be less...Read More »
Often, the first step in becoming comfortable with the CDI record review process comes from simply shadowing existing CDI staff members. If you are the first and only CDI specialist in your...Read More »
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 »
