An emergency department (ED) physician diagnosed a patient with pneumonia. He was concerned about a possible nosocomial etiology given the patient’s recent hospital discharge for problems related to atrial fibrillation. Because the patient’s Pneumonia...Read More »
There has been a considerable amount of confusion regarding physician terminology, documentation
requirements, and subsequent coding of various diagnostic bronchoscopic lung procedures. Because the current MS-DRG structure categorizes some of...Read More »
While most CDI specialists know to query for conditions related to malnutrition, such as obesity and cachexia, programs frequently ignore dietitians’ documentation and keep dietary professionals out of the coding/querying conversation when they should be partners at the table.Read More »
The American Hospital Association (AHA) does not plan to “convert” past issues of Coding Clinic for ICD-9-CM into new issues for ICD-10-CM/PCS, the AHA confirmed in a CMS teleconference held in November 2011. This decision caused concern...Read More »
In October 2010, when ACDIS first conducted its assessment survey regarding CDI readiness for ICD-10 implementation, 83% of respondents indicated they had no formal ICD-10 training and 44% indicated they had no training timeline (www.hcpro.com/...Read More »
The goals of coding should always be ensuring data accuracy and capturing a patient’s true clinical picture. Knowing the intent of an ICD-9-CM code is crucial. However, coding guidelines and official coding guidance sometimes conflict with these goals, putting...Read More »
With all of the attention around the increased specificity of ICD-10-CM codes, facilities are concerned that documentation will lack sufficient detail. And as CDI specialists know, physicians don’t always provide enough information for coders to choose the most specific ICD-9-CM code.