ICD-10-CM/PCS incorporates laterality, acuity, anatomical specificity, and a slew of additional combination and complication codes. Who will submit queries when this information is missing in a medical record? Will coders or clinical documentation improvement specialists take on this role? Cheryl Ericson, MS, RN, CCDS, CDI-P, and Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA, offer suggestions for determining who will submit queries.
If you’re worried about getting your physicians trained for ICD-10, you’re not alone. Thea Campbell, MBA, RHIA, Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, Donna Smith, RHIA, and Sue Belley , MEd, RHIA, CPHQ, offer tips and strategies to educate physicians about the new code sets.
ICD-10-CM/PCS incorporates laterality, acuity, anatomical specificity, and a slew of additional combination and complication codes. Who will submit queries when this information is missing in a medical record? Will coders or CDI specialists take on this role? Perhaps it might be a combination of the two.
Hospital medicine is a specialty that provides inpatient services for patients admitted to the hospital. Hospitalists are often called on to consult in regards to and to follow medical problems that occur during hospitalization for surgery, psychiatric hospitalizations, and obstetrical patients. Lois E. Mazza, CPC, explains how to correctly report hospitalist services.
The HIM profession is constantly changing, but HIM professionals are still responsible for maintaining the integrity of the health records. Lou Ann Wiedemann, MS, RHIA, FAHIMA, CPEHR, explains why HIM professionals can—and should—also play a role in clinical documentation improvement (CDI).
Coding managers and their team members sometimes must approach physicians in person regarding documentation. Clarification may be necessary, or perhaps you will need to coax the physician to complete certain records without further delay.
Physicians often use the acronyms IBS (which should indicate irritable bowel syndrome) and IBD (which should indicate inflammatory bowel disease) interchangeably even though they represent completely different conditions with different treatment and prognoses.
Emergency Departments (EDs) see a wide range of illnesses and injuries, from minor to major, which may require critical care. Lois E. Mazza, CPC, details how critical care is defined, what elements providers must document, and under what circumstances critical care can be coded for ED patients.
Do not view the proposed rule extending the ICD-10 implementation date from October 1, 2013, to October 1, 2014, as a year-long break from ICD-10 preparations. Rather, focus on using the additional time allotted to your advantage. This includes conducting documentation and coding assessments to gauge ICD-10 readiness. Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, explains why—and how—facilities should start assessing the readiness of their coding staff and documentation procedures in relation to ICD-10 requirements and create strategies to manage any deficiencies.
Coders and clinicians often seem to speak different languages. What a clinician considers important information may not be what a coder needs to assign the correct code. Clinicians may not document a piece of information that is vital to the coder. Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, Joseph Nichols, MD, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, explain how clinicians and coders can work together to improve communication.
These days, documentation improvement and compliance are at the forefront of coders' minds. In some cases, coders are led completely astray by bad data and physician documentation that isn't entirely accurate. Robert S. Gold, MD, emphasizes that it’s important for coders to always look at the larger clinical picture in the medical record—not just a documented laboratory result or change in vital sign. Gold applies this philosophy and examines a number of conditions, including anemia, acute kidney injury, congestive heart failure, and myocardial infarction.
How does medical necessity get “overlooked” on the physician side as well as the inpatient side? Case managers, utilization review staff, physician advisors, CDI specialists, and coders, each carry out specific duties and responsibilities when reviewing medical records. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, CCDS, examines contributing factors and takes a closer look at guidelines Trailblazer Health recently issued defining specific joint replacement (DRG 470) documentation that both hospitals and physicians should follow to support medical necessity.
Coders are constantly analyzing documentation for clues and details that may indicate the need for a physician query. For example, coders should watch for clinical evidence that points to a condition that the physician may not have explicitly documented. Coders also need to be wary of reporting conditions without accounting for context or other clinical indicators in the documentation. William E. Haik, MD, CDIP, explains how this can lead to inappropriate reporting of an MCC, for example, that the overall clinical picture does not support.
Can you begin to imagine how complex a piece of great literature would be if we had to include complete documentation of each medical incident? Or have to stop every time we have to develop physician...
