Q: If a complication was unavoidable, and has been documented as such, is that good enough reason to not code it? We wouldn’t mark a code as a patient safety indicator if it was an inherent part of the procedure, so would the same hold true for unavoidable complications?...Read More »
by Sharme Brodie, RN, CCDS
One thing many new CDI specialists hear—and many experienced CDI specialists attest to—is that the CDI profession requires an incredible amount of knowledge in numerous areas, not all of which you may have experience in. One such area may be neurology....Read More »
Q: I encountered clinical validation issues where documentation noted a diagnosis with criteria, but the criteria used didn't meet the definition. For example, noted sepsis with criteria of tachycardia and increased white blood cell (WBC) count. But, the patient’s heart rate (HR...Read More »
Andrea Johnson, RN, BSN, CCDS, the CDI specialist at Carolinas Rehabilitation in Concord, North Carolina, worked in the acute inpatient setting for six years before making a significant change.Read More »
As Robert S. Gold, MD, co-founder of DCBA, Inc. and founding ACDIS Advisory Board member, was fond of saying, “Pediatric medicine is not adult medicine for little adults.”Read More »
by Sharme Brodie, RN, CCDS
Many CDI and coding professionals let out a sigh of relief when the First Quarter 2017 edition of AHA Coding Clinic for ICD-10-CM/PCS arrived—it’s only 52 pages long, a novella compared to the voluminous tomes of previous editions. I looked at...Read More »
by James S. Kennedy, MD, CCS, CDIP, CCDS
Bronchopulmonary infections, such as acute bronchitis and pneumonia, represent frequent reasons for physician and facility encounters, resulting in ICD-10-CM code assignments that factor greatly in severity and risk adjustment inherent to...Read More »
by Joel Moorhead, MD, PhD, CPC
This article is about bringing the patient to the center of clinical validation. A patient with an “atypical” presentation, by definition, may have the disease but might not meet “typical” criteria for diagnosis.Read More »