In the intricate web of today’s U.S. healthcare landscape, every diagnosis, treatment, and procedure holds significance for financial management and quality of care. Amid the myriad of conditions and diseases, “probable” catheter-...Read More »
by Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC
As CDI professionals, we face a challenge when the clinical meanings of words do not match the ICD-10-CM classification system. For records related to matters of the heart, the meanings of such words—e.g., chest pain, ischemia...Read More »
Breast cancer mortality decreased 58% from 1975 to 2019, the likely result of breast cancer screenings and new treatments, according to an article released in JAMA.
Q: What terms need to be included in physician documentation to code in ICD-10-CM whether the patient’s migraine is chronic, intractable, or with status migrainosus?
A: “The patient has a migraine,” is insufficient documentation. Let’s...Read More »
by Laurie L. Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC
Perhaps because the profession of CDI is derived from so many disciplines (including coding, HIM, and clinical expertise) and supports so many efforts (such as risk adjustment, quality measure reporting, population health,...Read More »
Fights happen. On the playground. In the classroom. In the kitchen. Conflict is a normal part of the human experience; however, when a final DRG and a working DRG get into a fight, sometimes they need a few CDI specialist helping hands to resolve the issue....Read More »
Over the course of the past year while conducting severe malnutrition audits, I've found some cases where severe malnutrition and morbid obesity co-occur in the documentation. So far, I have observed seven cases where this has happened...Read More »