by Trey La Charité, MD
Every institution reading this column has likely received its first recovery audit contractor (RAC) denials regarding the documentation and coding of excisional debridement procedures (86.22).
Our hospital is no exception. While we knew that this...Read More »
According to the 2010 Physician Query Benchmarking Report (to be released later this month) 54% of the more than 300 respondents said they follow AHIMA’s guidance fully. Another 21% indicated they had read and incorporated portions of the guidance, while 7% indicated their facilities maintain...Read More »
As of January 1, a dozen ACDIS advisory board members will step down after leading the organization they helped create three years ago.This diverse group infused the association with a wide breadth of expertise and also reinforced the fact that CDI is not limited to nursing or HIM professionals...Read More »
Learning how documentation opportunities can maximize efficiency and overall cost-effectiveness is something to be passionate about. Working as a patient care nurse was extremely rewarding, but as a CDI professional I am now able to affect my...Read More »
This is a classic documentation opportunity to clarify “volume/fluid overload,” says Lynne Spryszak, RN, CPC-A, CCDS, CDI education director for HCPro, Inc., in Danvers, MA. “If the physician hasn’t documented acute CHF, I would hesitate to ask for this condition based on this mild BNP elevation...Read More »
Few managers have the luxury of hiring staff with concurrent record review experience. Thus, once you hire new staff, you need to determine how to train them. Even if the new hire is an experienced nurse who understands core measures, “you can’t just throw him or her a problem list and set them...Read More »
Q: A 79-year-old male nursing home patient presents with lethargy, confusion, and fever after failing an outpatient course of Bactrim for a suspected urinary tract infection (UTI). His white blood count is 22,000, segs 85, bands 10, and blood cultures are negative. He has a temperature...Read More »
