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 »
Three types of mistakes—insufficient documentation, miscoded claims, and medically unnecessary services and supplies—accounted for nearly 98% of errors common across six different provider types, according to the July 14 report ...Read More »
In response to a 30-question survey, 482 CDI professionals provided data about the number of staff they employ, the number of queries they generate, and the number of chart reviews their staff perform. They offered information on the focus of their CDI programs and to whom their CDI specialists...Read More »
It’s not enough to know whether heart failure is systolic or diastolic. Congestive heart failure (CHF), for example, isn’t an inherent component of systolic and diastolic heart failure, according to Coding Clinic, fourth quarter 2004. That means CHF, when present, requires a second code...Read More »
Q: What should physicians know now about the level of specificity they’ll be required to document once ICD-10 takes effect? We’re concerned about a potential swell in the number of queries if we don’t begin to address documentation...Read More »
If a coder reviews the chart of a patient in the emergency department (ED) or intensive care unit with documented symptoms, such as fever (or low temperature), elevated white cell count (or low white cell count), altered mental status, evidence of an...Read More »
There may be hope for hospitals carefully watching the proposed IPPS rule, praying for some amelioration of the suggested 2.9% documentation and coding adjustment (DCA) it included. On July 12, 242 members of Congress...Read More »
