Below is a complete listing of all CDI articles that have appeared in JustCoding News.
March 27, 2012
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.
March 27, 2012
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.
March 27, 2012
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.
March 13, 2012
Physicians use a lot of shortcuts and abbreviations. Some of them may even make it onto the official abbreviation list at their hospital. Some don’t. And even if they did, some physicians will use the wrong term. Robert S. Gold, MD, discusses an example that was featured in the January Medicare Quarterly Provider Compliance Newsletter regarding proper identification and ICD-9-CM coding of a bronchoscopy with biopsy (TBB) vs. a bronchoscopic lung biopsy (TBLB).
March 13, 2012
What should inpatient coders remember about the three-day payment window requirements? Although it may seem counterintuitive, Debbie Mackaman, RHIA, CHCO, and Marion G. Kruse, RN, MBA, explain that inpatient coders need to be aware of certain outpatient services that they may need to include on inpatient claims, as well as when they need to alert billers to assign condition code 51.
February 28, 2012
Robert S. Gold, MD, discusses updates to the code definitions and exclusions for various lung diseases, such as pulmonary insufficiency and respiratory failure, and cautions coders about the potential for over-reporting conditions that patients don't have or for identifying conditions that do not meet the intent of the codes.
February 28, 2012
Even if you didn’t make a personal New Year's resolution, you should make a professional one: to be more conscientious when scrutinizing physician documentation. Experts say every coder should scrutinize physician documentation, especially with ICD-10-CM/PCS looming on the horizon. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, and Dinh Nguyen examine the role coders play in determining diagnosis quality and accuracy.
February 21, 2012
Payers are now looking to ensure that physician and facility billing match, which could mean new vulnerabilities for hospital and physician reimbursement. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDIS, CCDS, and Avery E. Trickey, RHIA, explain how this also represents a new opportunity for CDI specialists: outpatient record review.
February 14, 2012
A great storyteller understands that it’s all in the details. Perhaps it’s the back-story about a particular character or maybe it’s the little facts peppered throughout the tale, but it’s the details that convey the essence of the story. Likewise, some ICD-10-CM injury codes tell only part of a patient’s story. Lolita M. Jones, RHIA, CCS, and Donna M. Smith, RHIA, discuss how to report associated injuries and complications and also talk about why it’s so important to have a firm grasp on anatomy and physiology to ensure accurate coding.
February 14, 2012
The American Hospital Association does not plan to “convert” past issues of Coding Clinic for ICD-10-CM/PCS. Lynne Spryszak, RN, CCDS, CPC, discusses why this decision has caused concern among coders and clinical documentation improvement specialists, who for years have relied on the guidance published in Coding Clinic to assist with coding complicated diagnoses or procedures.