When Dee Banet, RN, MSN, CCDS, CDIP, and her CDI team sent out a claim for a surgical patient with body mass index (BMI) greater than 40 with morbid obesity as a secondary diagnosis, they did not expect the claim to be denied; after all they...Read More »
For the past few years, healthcare professionals have focused on ICD-10 preparation. That prep work paid off—the transition has been largely successful. But facilities are experiencing a few bumps as their focus shifts from preparation to improvement of clinical documentation and coding. We...Read More »
No one thought ICD-10 implementation was going to be easy, but after a few months of working with the new code set, 19% called their implementation process just that—easy. Another 73% said implementation was only moderately challenging, and just a handful called it “difficult,” according to an...Read More »
by Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS
Some interesting tidbits of information can be gleaned from the most recent release of AHA Coding Clinic for ICD- 10-CM/PCS to help coders as they work in the new code set. I never thought I’d be so eager...Read More »
Quadriplegia is a very familiar condition that would never go unnoticed and undocumented in the medical record. The causes are typically catastrophic damage to the upper spinal cord due to trauma, vascular injury, or neoplasm...Read More »
As CDI programs move deeper into the post-implementation world, staff are identifying those changes that are having the greatest effect on DRG assignments, and those they are struggling with. Here are a few documentation issues that stand out.Read More »
ICD-10-CM/PCS brought some new challenges in coding neonatal records. The term “newborn” has replaced the term “fetus or newborn” in the ICD- 10-CM code set. This change ensures that these codes will only be used on the neonate’s...Read More »
The AHA’s Coding Clinic for ICD- 10-CM/PCS, Third Quarter 2015, opens with a discussion of the differences between excisional and non-excisional debridement—diagnoses with a long history of causing coding and clinical documentation...Read More »