Below is a complete listing of all CDI articles that have appeared in JustCoding News.
April 12, 2011
The specificity of ICD-10-CM/PCS, as well as the increased use of combination codes, will require that coders increase their level of knowledge in medical terminology and anatomy and physiology (A&P). While physician documentation for the service performed will always determine the code selection, Kimberly Reid, CPC, CPMA, CEMC, CPC-I, explains that without an understanding of A&P, coders may overlook or misunderstand information, resulting in inaccurate code selection.
April 12, 2011
Did the patient have an adverse effect from a specific drug, or was it a poisoning? The answer to this question often lies buried within physician documentation, and coders should take the time to review all information in the record to ensure compliance and accurate code assignment. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and William E. Haik, MD, FCCP, share their insight and emphasize the importance of understanding pertinent definitions as well as the context the physician provides in the documentation.
March 29, 2011
Although coding for a tracheostomy seems fairly straightforward and coding guidance for reporting excisional wound debridements is not in short supply, CMS determined that these coding areas continue to be pain points for many providers. Pam Winegardner, AAS, CTR, discusses potential coding errors for these two areas, which CMS highlighted in the February issue of the Medicare Quarterly Provider Compliance Newsletter.
March 29, 2011
Somewhere between the third urgent item on your to-do list, getting your budgets prepared, and responding to the latest auditor's requests is the omnipresent responsibility of nurturing the validity of the medical record. Darice Grzybowski, MA, RHIA, FAHIMA, explains the importance of examining data integrity issues affecting work flow and emphasizes the integrity of data as records become automated and more intensely complex and interoperable through sharing of data.
March 15, 2011
Operative reports can be a gold mine of information, far surpassing often vague or generalized progress notes, but sometimes this resource is left completely untapped, says Lynne Spryszak, RN, CCDS, CPC-A, who emphasizes that increased regulatory compliance and auditor scrutiny make it essential for coders to review the complete operative report before coding.
February 15, 2011
A patient’s medical record could include a laundry list of diagnoses, but not all of these conditions may be reportable. Coders must determine when they can report conditions as “other” secondary diagnoses and when they must simply leave them off the claim entirely. Gloryanne Bryant, RHIA, CCS, CCDS, and Laura Doty, RHIT, explain the definitions and guidelines for reporting secondary diagnoses and address the importance of thorough documentation to ensure compliant coding.
January 4, 2011
QUESTION: A consultant recently suggested that if we ask a physician to clarify systolic/diastolic on a query form for congestive heart failure (CHF), it might be construed as leading the physician if there had been no previous mention of systolic/diastolic anywhere else in the chart. We never place a query unless the physician states CHF in chart, but we query for it if the physician does not specify the type. If we include the phrases systolic/diastolic on the query form, is that considered introducing new information?
December 7, 2010
Think twice before you assign an ICD-9-CM code for a sign or symptom. Why? Signs or symptoms that are routinely associated with a more definitive disease process shouldn't be assigned as additional codes unless otherwise instructed by ICD-9-CM. Darren Carter, MD, and James S. Kennedy, MD, CCS, explain that when they're related—but not integral—to another condition, they should never be sequenced as a principal diagnosis.
October 12, 2010
Next year, CMS will investigate removing encephalopathy from the MCC list. CMS believes physicians were using this term inappropriately and thus incurring overpayments. To address this, James S. Kennedy, MD, CCS, discusses why it’s important for hospitals and coding staff to partner with their physicians to advise CMS on the proper use of the term and reimbursement for patients with encephalopathies.
September 25, 2010
Several recovery audit contractors (RAC), when describing the July 2010 CMS-approved audit issue “Inpatient Admissions without a Physician's Inpatient Admit Order,” said, “Admissions to the inpatient setting require a physician's order in order to qualify and be paid as an inpatient stay.” Elin Baklid-Kunz, MBA, CPC, CCS, discusses RAC guidance and explains what qualifies as a valid order.