If you are from the South, football is all that matters. I grew up in Alabama and now live in Mississippi. You have to understand that this time of year all we care about is tailgating and football. So my advice is to weave an analogy...Read More »
Documentation is central to accurate coding and reimbursement. It justifies treatment, supports the diagnosis, and captures patient severity and acuity. None of that comes as a surprise to coders, who often have to deal with documentation shortcomings.
Q:Some of our physicians have started documenting “aspiration without pneumonia.” When I questioned one of them about it, he said the patient had acid pulmonary syndrome/Mendelson’s syndrome. When I told the physician that this condition maps to the code for pneumonia,...Read More »
Many CDI specialists don’t spend a lot of time working with obstetric (OB) records, or may even ignore them altogether, principally because of the ICD-9-CM Chapter 11 coding guideline that basically says that pregnancy overrides...Read More »
A patient’s medical record contains a wealth of information about his or her hospital encounter, including diagnoses, treatments, operative reports, and ancillary notes. Unfortunately, much of the detailed information found in a patient record is...Read More »
I’m an old (and I do mean OLD) ICU nurse. As a working nurse, my relationships with physicians usually centered on getting them to listen to my assessments: Yes, you need to get out of bed and come see this patient who has stopped...Read More »
The length of stay (LOS) for coronary artery bypass graft patients and valve replacement patients at York Hospital (YH)/ Wellspan Health was significantly higher than the Medicare geometric mean length of stay (GMLOS) according to results of a record...Read More »