Paul Evans, RHIA, CCDS, CCS, CCS-P, tackles the various characteristics of creating a query and says that while all portions of any program, such as education and metrics, are important, the proper formulation of a query represents the most important task for a CDI professional.
James S. Kennedy, MD, CCS, CCDS, CDIP, writes about potential coding compliance issues raised in the Office of Inspector General’s (OIG) Work Plan for providers to consider, including documentation and coding for severe malnutrition and bariatric surgery.
Q: If a patient is admitted with a high blood alcohol level and the provider documents the blood alcohol level in his or her note, does the provider also need to specifically write “patient with intoxication?”
Medical necessity denials are commonly encountered in facilities. Complete understanding and utilization of the ICD-10-CM/PCS coding guidelines is imperative for coders and coding mangers to recognize how to avoid these denials. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The cost for a hospital stay in 2014 involving acute renal failure (ARF) averaged $19,200, nearly twice the $9,900 average cost for stays not involving renal failure, according to the statistical brief published by The Healthcare Cost and Utilization Project (HCUP).
Allen Frady, RN-BSN, CCDS, CCS, CRC, explains the value of tracking and understanding key performance indicators (KPI), and gives advice on how facilities can improve on its practices.
Hospitals reduced central line-associated bloodstream infections (CLABSI) by 50% between 2008 and 2016, according to a new report released by the Centers for Disease Control and Prevention (CDC).
Q: According to the ICD-10-CM Official Guidelines for Coding and Reporting, uncertain diagnoses should be documented at the time of discharge. If a consultant documents an uncertain diagnosis in the final or last progress note and not in the discharge summary, can we code that uncertain diagnosis?
Emergency departments at designated trauma centers encounter some of the most complex patients—and with them, a complicated documentation web that’s difficult to untangle, making trauma case review essential for hospitals.
According to the American Cancer Society, in 2017 there were an estimated 1,688,780 new cancer cases diagnosed and 600,920 cancer deaths in the U.S. In this article, Peggy Blue, MPH, CCS, CCS-P, CPC, CEMC , breaks down the usage of the ICD-10-CM neoplasm table and reviews coding for neoplasm admissions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
