Q:A patient is admitted with an elective colon resection. The physician documents postoperative ileus but then on the day of discharge the notes states: expected postoperative ileus. So do we add the code 997.4 or not?
We are currently seeking speakers to present at the 2011 ACDIS Fourth Annual Conference, to be held April 7-8, 2011 at the Hilton Walt Disney Resort in Orlando.
Speakers willing to present on all aspects of clinical documentation are welcome and we encourage new and unique ideas. Case...Read More »
The Centers for Medicare & Medicaid Services (CMS) recently approved the first “medical necessity review” audits for the recovery audit contractor (RAC) program,...Read More »
When the University of Medicine and Dentistry of New Jersey (UMDNJ) hired Melanie Halpern, RN-BC, MBA, CCDS, CCRA, to implement a clinical documentation and coding integrity (CDCI) program, administration allotted three full-time positions to staff the 550-bed academic medical center....Read More »
It may be too early to start intensive ICD-10-CM training for your coding and CDI team, but now is a good time to at least become familiar with features of the new system.
During CMS’ Basic Introduction to ICD-10-CM National Provider Call held earlier this year, Sue...Read More »
Q: We had a patient come in for back pain and treatment for a possible neurological impingement. However, after a five-day stay, the physician documents neck mass and for the remainder of the stay the resources appear to have been focused on that treatment. How do I discern the principal...Read More »
