Recently, I was asked an interesting question about querying for the diagnosis of encephalopathy. The student asked whether it was required for a patient to return to their mental status baseline prior to the CDI specialist querying the...Read More »
By Howard Rodenberg, MD, MPH, CCDS
When my son was in middle school, I would call him every evening to review the school day. I would want to know all about the things he was learning and the friends he was making, and he would grudgingly oblique me with a one-word answer if he...Read More »
ICD-11 reflects critical advances in science and medicine and is the first code set revision to be well integrated with EHRs and information systems, the WHO says.Read More »
By Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS
As I sat down to summarize the proposed fiscal year (FY) 2019 ICD-10-CM update, the number of changes are significantly less than the prior two years which makes me think we’re getting back to the norm of expected yearly...Read More »
A common theme that plays a critical role in portraying the patient encounter accurately in both the inpatient and outpatient environments is complete and precise documentation. General principles of medical record documentation...Read More »
Q:I'm in charge of a coding audit for our department for the first time and trying to determine how many cases to use as a sample. What factors should I consider?Read More »