Clinical documentation plays a vital role in all coding. It is especially important, however, when reporting conditions such as stroke, which more often than not involves multiple symptoms, diagnoses, and complications.
Through the years, The American Hospital Association’s (AHA) ...Read More »
The transition from ICD-9-CM Volume 3 procedure codes to ICD-10-PCS will be by all accounts a significant adjustment, writes Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CEMC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., and an AHIMA-certified ICD-10 trainer. In her...Read More »
by Trey La Charité, MD
Every institution reading this column has likely received its first recovery audit contractor (RAC) denials regarding the documentation and coding of excisional debridement procedures (86.22).
Our hospital is no exception. While we knew that this...Read More »
Learning how documentation opportunities can maximize efficiency and overall cost-effectiveness is something to be passionate about. Working as a patient care nurse was extremely rewarding, but as a CDI professional I am now able to affect my...Read More »
Q: A 79-year-old male nursing home patient presents with lethargy, confusion, and fever after failing an outpatient course of Bactrim for a suspected urinary tract infection (UTI). His white blood count is 22,000, segs 85, bands 10, and blood cultures are negative. He has a temperature...Read More »
Q: I am unsure how “ribs” are categorized in ICD-10. I don’t understand if taking one rib is considered a resection or an excision and why. The coder coded the following record to total ostectomy-rib. If you crosswalk the ICD-9-CM Level 3 code to ICD-10-PCS, it maps to a resection. I...Read More »
I realize that many of the faithful members of ACDIS are, indeed, coders, but most of us have a nursing background, so I’m going to give my two-cents on the coding/CDI specialist relationships from a nursing perspective and hope that...Read More »
