Operative reports can be a gold mine of information, far surpassing often vague or generalized progress notes, but sometimes this resource is left completely untapped, says Lynne Spryszak, RN,CPC-A, CCDS. Coders know they should review the complete operative report before coding...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 »
In March 2008, the National Kidney Foundation sent a letter to the National Centers for Health Statistics and asked that the term “acute kidney injury” (AKI) be an optional phrase for assigning...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 »
Q: Our CDI specialists call the physicians when queries have not been answered. Sometimes the physician will give us an answer over the phone. I’m wondering if that’s okay. Can our CDI staff, who are registered nurses, take the verbal...Read More »
Q: Is systemic inflammatory response syndrome (SIRS) an inherent part of an infection? For example, when a patient comes in with pneumonia, and clinical indicators are present for SIRS but the physician did not specifically write SIRS, should coders or CDI specialists query physicians?...Read More »
As facilities vie for government incentives to implement electronic health record systems they may find CDI programs provide a hidden benefit.
The biggest challenge related to meeting governmental standards for “meaningful use” of EHR “is that they require physician documentation and...Read More »
Confusing coding guidelines and insufficient documentation have made neoplasms a target area as HealthDataInsights—the RAC for Region D—recently said it will take a closer look at MS-DRGs 837–948.
“…[T]here are opportunities for error within this subset of MS-DRGs,” says Paul Evans,...Read More »
