Generative artificial intelligence (AI) offers benefits in medicine but poses risks to medical trainees, including skill loss and outsourcing reasoning that can potentially undermine clinical competence and patient safety, according to a recent...Read More »
According to a clinical review published in the Journal of the American College of Cardiology, atherosclerotic cardiovascular disease remains a leading cause of morbidity and mortality worldwide, with acute myocardial...Read More »
Q: I primarily work in the neurosurgery review lane within CDI and am seeking further guidance on best practices for capturing loss of consciousness (LOC) status in cases of traumatic subdural or subarachnoid hemorrhage. Current definitions of LOC appear broad and can be challenging...Read More »
Q: What are some documentation gaps in behavioral health encounters?
A: Many times, we see a lack of specificity regarding symptoms, severity, and treatment details required for accurate ICD-10-CM coding, as well as incomplete...Read More »
Q: How are outpatient consultations reported? And what qualifies as a consultation?
A: Outpatient consultations are reported with CPT codes 99242-99245. Each has a time and a level of medical decision-making (MDM). You report either the time or MDM. Here's an overview:...Read More »
Q: What is the correct ICD-10-CM coding approach for poisoning cases that include documented manifestations, and how are these cases reflected in code selections and sequencing?
A: Let’s look at two examples of poisoning, one accidental and the other intentional...Read More »
