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.
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.
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.
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.
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.
Professional development in CDI is a multifaceted and continuous journey, demanding integration of specific knowledge, continuous learning, and adaptability.
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.
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.
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.
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.
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.
Clinical validation has become one of the hottest targets in payer auditing. Denise Wilson, MS, RN, RRT, writes about strategies facilities can use to appeal clinical validation denials.
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.
Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , summarizes the highlights from the newest installment of Coding Clinic, which includes guidance on reporting pancytopenia, inherent conditions, ORIF, and neurally adjusted ventilatory assist devices.
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.
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.
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.
Surgeons are often the toughest contingent of any medical staff with which a CDI program must make headway. Understanding a little surgeon psychology is the key to making positive inroads. Surgeons see themselves as “doers” or “fixers,” while they consider most other medical specialties as “thinkers” who are not “doers.”
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.
Kate Siemens, RN, CMSRN, CCDS, conducts an interview with Majed Gharfeh, MD, to offer a physician’s perspective on queries and tips on how coders can receive the best results from querying their providers.
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.
Learn about the challenges faced and collaborative opportunities encountered by one organization when it began the process of improving its observed-over-expected mortality ratio.
Key performance indicators are used by organizations to monitor the progress of CDI initiatives. Waldo Herrera, MD, MBA, MSc, FACP, SFHM, CHCQM-PHYADV , describes performance metrics that professionals at his facility use to track revenue cycle performance and opportunities for improvement.
Modifier -25 is used to report a significant, separately identifiable E/M service by the same physician. Courtney Crozier, MA, RHIA, CCS, CDIP , reviews the American Medical Association’s guidance on correct reporting of modifier -25, and outlines when and how to report it.
What may be considered a simple task, such as confirming present on admission status, can be complicated by discrepancies between coding and quality reporting criteria. Kate Siemens, RN, CMSRN, CCDS , outlines the ways in which coding and quality metrics do not align.
The gap between clinical reality and coding terminology can be addressed by empowering coders to use clinical judgment. Merle Zuel, RN, CCDS , discusses when it is appropriate for coders to interpret provider documentation and use their clinical judgment to code it in a certain way.
What may be considered a simple task, such as confirming present on admission status, can be complicated by discrepancies between coding and quality reporting criteria. Kate Siemens, RN, CMSRN, CCDS , outlines the ways in which coding and quality metrics do not align.
Kerri Swart, RN, CCRN, CCDS, writes about how a previously 100%on-site CDI program shifted to remote work and maintained productivity and education standards.
CMS’ quality measures rank hospital mortality data as better than, no different than, or worse than the national mortality rate. JoAnne Mullins, DNP, MSN, RN, CCDS , describes how to perform quality reviews targeting missed coding opportunities and other factors that influence mortality data.
The beginning of March brought the release of the first quarter 2023 Coding Clinic . Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC, summarizes key information provided in this publication, including analysis of ICD-10-CM guidelines , code changes, and coding Q&As.
Expanding into psychiatric units or facilities is a step that CDI programs may take because of their current patient population, a newly acquired center, or just another chance to improve their risk adjustment factor (RAF) score.
Kathleen M. Romero, MSN, RN, EBP-C, Cynthia Beal, MBA-HCM, BSN, RN, and Renee Pate, MSOL, MSN Ed., RN, CCDS, explain how they implemented a CDI program in their facility’s emergency department and the how establishing this program improved coding accuracy and increased reimbursement.
Approximately 1.7 million adults in America develop sepsis each year, according to the Centers for Disease Control and Prevention. Review documentation requirements and ICD-10-CM coding for severe sepsis.
Though outpatient settings have in some form been reviewed by CDI specialists practically since CDI itself started, this progress remains slow and steady for a reason.
