Q: Whenever we get a trauma patient, it’s either very easy to get to the multiple significant trauma (MST) major diagnostic category (MDC), or it becomes a real challenge, especially taking into account the rules pertaining to two body sites...Read More »

Recent approval of a RAC issue for inpatient hospital claims review has initiated uncertainty and places an onus on providers to lean on CMS guidance and policy manuals. The issue, “inpatient admissions without a physician’s inpatient admit order,” can be referenced in the Medicare Claims...Read More »

Retaining written, templated, and verbal queries in document form is necessary to ensure CDI compliance. In the current climate of regulatory agencies (e.g., recovery audit contractors and Medicare administrative contractors), it’s a good practice to maintain queries as part of the permanent...Read More »