Artificial intelligence (AI) has burst on the scene with numerous clinical and coding applications for providers. This article looks at how the technology can be used and where human oversight is still required.
Penny Jefferson, MSN, RN, CCDS, CCDS-O, CCS, CDIP, CRC, CHDA, CRCR, CPHQ , explains how professional development in CDI is a journey, demanding integration of specific knowledge, continuous learning, and adaptability.
Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CCS , defines the Diagnosis, Etiology, Evidence, Plan (DEEP) methodology to identify and instill good habits for provider documentation.
Nancy Reading, RN, CPC, CPC-P , explains how employing clinical and coding criteria for assigning or auditing ICD-10-CM codes for malnutrition can have a significant impact on reimbursement. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: Can a “yes/no” query be sent based on this documentation to confirm yes, there is a postoperative hematoma, no, there is not a postoperative hematoma, or other?
April Russell, MBA, CPC, CPC-P, COC, CRC, CCDS-O , and Will Morriss, CCS, CCDS-O , describe how artificial intelligence (AI) has impacted providers, coders, and the healthcare industry.
This Q&A with Nancy Enos, FACMPE, CPC-I, CPMA, CEMC , covers independent historians, independent interpretations, discussion with external physicians, risk, and billing for separate E/M visits. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Professional development in CDI is a multifaceted and continuous journey, demanding integration of specific knowledge, continuous learning, and adaptability.
April Russell, MBA, CPC, CPC-P, COC, CRC, CCDS-O, and Will Morriss, CCS, CCDS-O, describe how artificial intelligence (AI) has impacted providers, coders, and the healthcare industry.
Amanda Vincent, MBA, CCS, CPC, CCDS, CRC, explains the differing definitions of “complication” for providers vs. coders, reviews types of complications, and codes an intraoperative laceration case study.
This Q&A is part of an interview with Nancy Enos, FACMPE, CPC-I, CPMA, CEMC , covering physician CPT E/M reporting and medical decision-making. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a broad federal law that establishes the basic privacy and security protections that coders are required to follow.
The healthcare setting can feel like a courtroom in the denials and appeals arena. By assessing the effort that goes into an appeal and the difference that comes out of them, coders and CDI specialists may find that the chasm between clarifying a patient record and defending it isn’t as wide as they think.
After years of working to engage providers and get them on board with CDI efforts, every seasoned CDI professional knows there’s no one-size-fits-all solution.
Anemia describes a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient. Review the types of anemia, diagnostic criteria, treatment, and ICD-10-CM coding.
Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM, delves into the ethical standards, best practices, and importance of accurate health record documentation in regard to heart failure by drawing insights from authoritative sources within the industry.
Does the data collected by your healthcare system truly represent the patient you are caring for? Andrew B. Maigur, MD, CHCQM-PHYADV, CMPC, writes about how documentation is critical to capturing data for accurate coding and quality metric reporting.
Kate Siemens, RN, CMSRN, CCDS , discusses the clinical indicators for malnutrition during end-of-life care with Taylor Kuykendall, MS, RD, LD . She covers relevant ICD-10-CM codes and proper reporting methodologies for the condition.
Despite sepsis being the leading cause of hospital readmissions and in-hospital deaths in the U.S., its extensive history of clinical definitions and criteria can cause confusion for even the most experienced coders. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
