Each facility should have a specific plan in place between CDI and coding for how to handle unspecified diagnoses, says Katy Good, RN, BSN, CCDS, CCS, CDI coordinator at Flagstaff Medical Center in Arizona. Her facility opted to focus primarily on two things when it came to ICD-...Read More »
Quadriplegia is a very familiar condition that would never go unnoticed and undocumented in the medical record. The causes are typically catastrophic damage to the upper spinal cord due to trauma, vascular injury, or neoplasm...Read More »
As CDI programs move deeper into the post-implementation world, staff are identifying those changes that are having the greatest effect on DRG assignments, and those they are struggling with. Here are a few documentation issues that stand out.Read More »
ICD-10-CM/PCS brought some new challenges in coding neonatal records. The term “newborn” has replaced the term “fetus or newborn” in the ICD- 10-CM code set. This change ensures that these codes will only be used on the neonate’s...Read More »
The AHA’s Coding Clinic for ICD- 10-CM/PCS, Third Quarter 2015, opens with a discussion of the differences between excisional and non-excisional debridement—diagnoses with a long history of causing coding and clinical documentation...Read More »
In the past 15 years at Sarasota Memorial Health Care System in Florida, there were two unsuccessful attempts to implement a CDI program. So when Joannie Crotts, RN, BSN, CPC, took on the project back in 2011, shortly after accepting her first CDI position, she had her hands...Read More »
The CDI Journal offers CE credits towards the ACDIS CCDS certification. To obtain your CCDS continuing education credits, you must successfully complete the online continuing education quiz. Please note: The expiration date for this activity is January 1, 2017. You must complete your online quiz...Read More »
