Contractors could use a little guidance from CMS to do a better job at reviewing medical records for electronic health record (EHR) problem areas. For example, clues within the progress notes, hand writing styles, and other attributes that help corroborate the authenticity of paper medical...Read More »
Thankfully, some of the documentation and coding issues I have been screaming about over the past 10 years have been heard with the transition to ICD-10.Read More »
Of the nearly 450 respondents to a recent ACDIS website poll, 50% say they conduct pre-payment record reviews, with an additional 7% indicating their facility is considering implementing such reviews in 2014. Of that 50%, 35% of...Read More »
What is the correct code assignment for a diagnosis of postoperative aspiration pneumonia? ICD-9-CM’s Tabular List under code 997.39 provides the following inclusion terms: “Pneumonia (aspiration) resulting from a procedure.” However, the instructional note under category 997 states, “Use...Read More »
Q: We are struggling with how to query physicians regarding complications of procedures or surgeries. For example, a patient was readmitted for a bile leak two weeks after a cholecystectomy. Neither the attending nor the GI consultant ever stated that this was a complication. Can you...Read More »
“If ICD- 10-PCS is not necessary, why the debate? Why should we bother assigning codes when we don’t have to?”The ICD-10 system was designed to improve clinical communication via modernization and standardization of codes and descriptions. The ICD-10-PCS side provides additional specificity to...Read More »
In 2008, only 11% of respondents to an ACDIS poll indicated their CDI program either reviewed outpatient records for documentation improvement opportunities or were looking to expand into outpatient areas (8% and 3% respectively).
How has the climate changed? Of the more than 400...Read More »
Genevir O. Del Mundo, CDIP, CCS, CCA (“Apple” to his friends), a CDI specialist at Kindred Hospital, grew up in the Philippines watching his father help people and save lives. He always wanted to be a doctor, too, to follow in his father’s footsteps. Transitioning from one...Read More »
