In addition to the Official Guidelines for Coding and Reporting applicable to the inpatient code assignment and the ICD-10-CM/PCS code set, two sets of guidelines exist solely for evaluation and management (E/M) coding—...Read More »
Q: Which sepsis criteria should we use? It seems like we get denials quoting every criteria set and are at a loss for how to prevent them or respond.Read More »
In April 2012, the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (ASPEN) jointly published a...Read More »
Richard Pinson, MD, FACP, CCS, will present “A Deep Dive into HCCs” on Day 1 of the ACDIS Symposium: Outpatient CDI, which takes place November 14-15 at the Hyatt Regency in Austin, Texas. Pinson is the principal and medical...Read More »
Q: We recently had a patient come in with bilateral shoulder pain and numbness. The patient also had lung cancer, metastasized to spine. What should we sequence as the principal diagnosis? The patient is currently undergoing chemo therapy. Read More »
Q: I’ve heard that the provider should identify the level of substance consumption. For provider education, would the CDI department need to cite any clinical indicators that would help providers differentiate use, abuse, or dependence? Or should we...Read More »
By Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS
A commonly recommended audit sample size is 30 cases for routine quality auditing with no known serious compliance issues. Conducting an audit of this magnitude for every coder every month can be a daunting challenge....Read More »
Q: Recently, our inpatient psychiatric facility has been asking if it would be beneficial to have CDI review their accounts. I researched this a few years back and learned from other programs that there was little benefit as most psych DRGs are single...Read More »