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.
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.
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.
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.
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?
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.
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.
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.
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.
CDI departments have long been involved with the denials management process. As with any expansion of CDI responsibility, those looking to venture into a new area can glean valuable knowledge from those already on the cutting edge.
Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , reviews coding, CDI, and clinical validation challenges associated with acute kidney injury cases and gives insight into how coders and physicians can work together to increase accuracy.
Kellie Halsted, MSN/MHA, RN, CCDS, CCM , writes about how her experience as a hospital case manager has given her additional insight into writing clinical validation appeal letters as a CDI specialist.
Parkinson's disease is a chronic and progressive neurodegenerative disorder that affects the central nervous system. Debbie Jones, CPC, CCA , explains the symptoms, treatment, and how 2024 ICD-10-CM coding changes will affect reporting for this disease.
Hemodialysis involves diverting blood into an external machine, where it is filtered and returned to the body. Sarah Gould, CPC , describes the vascular surgical options for hemodialysis (fistulas and grafts), their various types, and how to report them in ICD-10-PCS. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
With certain medical conditions, encountering differing opinions and discrepancies in provider documentation is inevitable. Deanne Wilk, MPS, RN, CCDS, CCDS-O, CDIP, CCS , reviews 10 diagnoses whose documentation commonly features discrepancies.
The rise in remote work has enabled many healthcare systems to transition to a systemwide model. This change has left some CDI departments struggling to create a unified team. Learn from other facilities on how to overcome these challenges.
Amanda Vincent , Javier Ortiz , and Teresa Brown, RN, CCDS, CDIP, CCS , identify various CMS quality programs, discuss common conditions these programs assess, and highlight their impact on patient safety through examples and coding case studies.
Antibiotic resistance occurs when bacteria become resistant to drugs designed to kill them. Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, offers guidance on querying physicians for antibiotic resistance organisms.
