Q: What are some documentation gaps in behavioral health encounters?
A: Many times, we see a lack of specificity regarding symptoms, severity, and treatment details required for accurate ICD-10-CM coding, as well as incomplete...Read More »
Cardiac professionals may already be aware of porcelain aorta, but it was a subject that was new for me. The case I was reviewing was a patient who was being evaluated for a coronary artery bypass graft (CABG) but was deemed unfit for...Read More »
CDI has often been referred to as the bridge between the clinical and coding worlds, with the unique skill set and knowledge base that allows them to look at clinical medical record documentation and understand how it does (or does not) translate into codes...Read More »
Admit type continues to present a significant risk across hospital operations, driven by limited formal education and widespread misinterpretation of national standards. Outside the National...Read More »
If your CDI program hasn’t gotten involved in Patient Safety Indicator (PSI) reviews yet, it may only be a matter of time, and this year the 2025/2026 ACDIS CDI Leadership Council has gathered a Mastermind group dedicated to topics surrounding CDI and quality. (...Read More »
Copy-and-paste functionality—also referred to as copy-forward or cloned documentation—has become deeply embedded in EHR workflows. In an environment of escalating documentation demands, this functionality offers clinicians much-...Read More »
Let’s face it: Commonly used clinical vernacular within the medical record is sometimes out of step with today’s healthcare environment. Throughout training, providers learn terms, phrases, and charting techniques that are...Read More »
Q: How are outpatient consultations reported? And what qualifies as a consultation?
A: Outpatient consultations are reported with CPT codes 99242-99245. Each has a time and a level of medical decision-making (MDM). You report either the time or MDM. Here's an overview:...Read More »
