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.
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.
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.
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.
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.
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.
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.
Clinical documentation and ICD-10-CM coding terminology for neonatal conditions do not always match. Review documentation requirements and ICD-10-CM coding guidelines for reporting common neonatal diagnoses, as well as advice for querying pediatric healthcare providers.
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.
Jorde Spitler, RN, CDI manager at Dayton Children’s Hospital, describes key considerations for documentation review, querying, and ICD-10-CM coding in a pediatric acute care setting.
As healthcare systems look to replicate successful CDI programs outside of large complex community or academic health centers, there are unique considerations for rural settings.
Laura Roberts, BSN, RN, CCDS , describes how to perform internal reviews that target Patient Safety Indicators, hospital-acquired conditions, and other quality indicators.
There is no single query format every organization uses. Though guidelines exist, each CDI program and its leaders must ultimately determine how to maintain compliance.
Coding and CDI professionals should understand disease processes for common inpatient diagnoses. Ronald Singell, RN, BSN, CCDS , writes about clinical indicators of disease for diabetic ketoacidosis, gastrointestinal hemorrhage, and sequential organ failure.
Stacy Reck, MBA, RHIA, CDIP , and Ashley Wells, MN, RN, CMSRN, CCDS , describe common reasons for clinical validity denials and strategies they use to defend against them. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Auditors see assignment of certain MS-DRGs as a red flag and most often will pull these encounters for review. Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , describes these MS-DRGs and offers advice for ensuring accurate reporting of a principal diagnosis.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS , outlines benefits that come with being a physician advisor and how coding and CDI professionals can reiterate these to physicians who are interested in taking on this role.
