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 »
Jennifer Oetinger, RN, BSN, has created a poster entitled “Spinal surgery: Interpretation, opportunities, and coding.” Janet Barber, MBA, BSN, RN, CCDS, and other members of the Providence Health System team will be presenting the poster in Oetinger’s stead.Read More »
Q:We are having trouble determining what qualifies a patient as having an acute MI and what documentation would support the diagnosis. Can you help our coding team clarify?Read More »
By Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS
While I prefer the use of the term “coding review,” the industry commonly uses the term “coding audit” to describe the practice of reviewing the accuracy of code assignment. These audits are done based on the documentation...Read More »
