By Julian Everett, BSN, RN, CDIP
I clearly remember the day my director told me I’d be reviewing our pediatric mortality cases. I didn’t know where to begin, and our pediatric CDI program was only a year old. Before I could start tackling the problem, I had to learn as much about...Read More »
by Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS
In response to providers’ complaints of burdensome regulatory documentation, CMS proposed in July 2018 to reduce the number of evaluation and management (E/M) levels to two and reduce documentation requirements for...Read More »
by William E. Haik, MD, FCCP, CDIP
Complex pneumonias such as Gram-negative bacterial pneumonias and aspiration pneumonias segregate to a higher-weighted MS-DRG (MS-DRGs 177–179 [Respiratory Infections and Inflammations]) than simple pneumonias such as Streptococcus pneumoniae...Read More »
by Sharme Brodie, RN, CCDS
The last quarter of the year typically includes a large number of items for the American Hospital Association’s (AHA) Coding Clinic for ICD-10-CM/PCS publication. This recent release doesn’t disappoint, with a whopping 94 pages worth of material...Read More »
Documentation and coding myocardial infarction (MI) is a common pain point for CDI departments, caused by conflicting or incomplete documentation that requires further clarification with a query. Type 2 MI is frequently incorrectly diagnosed and...Read More »
“The clinical definition of myocardial infarction denotes the presence of acute myocardial injury detected by abnormal cardiac biomarkers in the setting of evidence of acute myocardial ischemia.”
