Lolita M. Jones, RHIA, CCS, owner of Lolita M. Jones Consulting Services in Fort Washington, MD, developed this chart to assist coders in choosing the correct excision code.
This Inpatient Physician Query Process form outlines a sample policy for querying physicians to clarify physician documentation whenever there is conflicting, ambiguous, or incomplete information in the medical record regarding any significant reportable condition or procedure. Learn more about HCPro’s Physician Queries Handbook by Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS, James S. Kennedy, MD, CCS, Marion Kruse, MBA, RN, and Lynne Spryszak, RN, CPC-A, CCDS, at the Healthcare Marketplace.
Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, an independent coding consultant in Melba, ID, shares this tool for auditing E/M codes and assigning the appropriate level code.
Use this sample reference tool to determine the chronological development of a patient's current illness from the beginning or from the previous encounter to the present. Michelle Solomon, BA, LPN, CPC, revenue team manager of primary care at Henry Ford Health System in Detroit provided this sample tool.
Ensuring accurate capture of injection and infusion administration and drug codes is an important part of ensuring your facility receives the reimbursement it deserves. Sharon Clayton, RN, MS, MBA, CPC, president of Key Healthcare Consulting, LLC, provided this sample injection and infusion handout to help with coding accuracy.
Use this sample query form for chest pain when you need more specific documentation from physicians. James S. Kennedy, MD, CCS, director at FTI Healthcare in Atlanta provided this sample form.
Use this sample query form for heart failure when you need more specific documentation from physicians. James S. Kennedy, MD, CCS, director at FTI Healthcare in Atlanta provided this sample form.
Use this sample query form for malnutrition when you need more specific documentation from physicians. Faye Anderson, RHIA, division director for HIM at Southeast Alabama Medical Center in Dothan, AL, provided this sample form.
Lori-Lynne Webb, CPC, CCS-P, CCP, an independent coding consultant in Melba, ID, shares this sample template for an initial preventive physical examination (IPPE). This can be a handy tool to ensure that physicians don’t overlook IPPE requirements.
This form, which is an excerpt from HCPro’s book, Orthopedic Coding Guide for Ambulatory Surgery Centers, Second Edition by Lolita M. Jones, RHIA, CCS, is a sample postoperative pain injection form that one surgery center developed to ensure comprehensive postoperative pain control documentation. For more information, please visit HCMarketplace.com
Care Plan at risk for Pressure Ulcers
Medicare Part B 2008 HCPCS and modifier annual update chart by Lori-Lynne Webb, CPC, CCS-P, CCP, independent coding consultant located in Melba, ID.
Sample policy on standardizing E/M audits
The form is used to measure a patient's degree of malnutrition.
HCPro's Association of Clinical Documentation Improvement Specialists (ACDIS) present a Blue chart designed to help clinical documentation of Bacteremia sepsis. If you aren't an ACDIS member but would like to become one, or if you would like to learn more about ACDIS visit the ACDIS Web site at http://www.cdiassociation.com/
HCPro's Association of Clinical Documentation Improvement Specialists (ACDIS) present a Present on Admission (POA) query form designed to help clinical documentation improvement specialists identify whether an associated condition was present at the time of the order for an inpatient admission. If you aren't an ACDIS member but would like to become one, or if you would like to learn more about ACDIS visit the ACDIS Web site at http://www.cdiassociation.com/
HCPro's Association of Clinical Documentation Improvement Specialists (ACDIS) present a heart failure chart designed to help clinical documentation improvement specialists identify signs and symptoms of heart failure in the medical record. If you aren't an ACDIS member but would like to become one, or if you would like to learn more about ACDIS visit the ACDIS Web site at www.cdiassociation.com
A fifth lymphatic and hematopoietic tissue category code digit denotes a specific location where the lymphoma occurs. For example, lymphoma can occur in any one of the following locations on the body:
When managers propose coder compensation levels to an organization's human resource department, they typically take into account both credentials and experience. For this reason, most HIM departments implement a coding career ladder that outlines objective and measurable criteria for advancement. The criteria must also define proficiency and can be tied to production expectations developed for the department. The following is one example of a coding career ladder. Consider implementing a similar system in your hospital if you don't already have one in place.
Use this acute respiratory failure documentation prompter to help prompt physicians to document language that will affect severity-adjusted DRGs.
Use this card to help prompt physician documentation for various cardiovascular conditions.
Use this prompter to help capture cardiac CCs.
Use this nifty form to track discharges, final diagnoses, and more. Source: North Kansas City (MO) Hospital. Reprinted with permission.
Use this chart to ensure that critical elements appear on your history and physical forms. Source: Adapted from: Ongoing Records Review, Third Edition: A Guide to JCAHO Compliance and Best Practices, Coyright 2003, HCPro, Inc.
Use this nephrology attending evaluation to track patients' condition. Source: Oregon Health & Science University, Portland. Reprinted with permission.
Use this form to track queries as well as post-query payments. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-1047.html
Use this form to help clarify physician signatures in the medical record. Source: Medical College of Ohio Hospitals. Reprinted with permission.
Use this tool to clarify respiratory failure and query physicians for documentation improvement. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit: http://www.hcmarketplace.com/prod-1047.html
This pocket guide for cardiology physicians includes common cardiology DRGs, common cormorbidities, and common conditions of catheterization patients. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-1047.html
Use this sample letter when appealing denials at your facility. Source: Denial Management: Key Tools and Strategies for Prevention and Improvement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-3659.html
Use this form to track documentation and quality deficiencies. Source: Adapted from: Seven Steps to HIM Compliance, copyright 1998 HCPro, Inc.
These facility E/M guidelines use a point system to determine each level of care. Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission. For More information visit: http://www.hcmarketplace.com/prod-1740.html
These facility E/M guidelines use staff intervention to determine each level of care. Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission. For More information visit: http://www.hcmarketplace.com/prod-1740.html
This set of facility E/M guidelines uses time as a determining factor for each level of care. Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission. For More information visit: http://www.hcmarketplace.com/prod-1740.html
Use this template for a general progress note. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-1047.html
These observation services guidelines define observation, explain average lengths of stay, outline what observation excludes, explain necessary documentation, and discuss medical neccesity. Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission. For More information visit: http://www.hcmarketplace.com/prod-1740.html
Use this sample metric template for RVUs, uncollectable AVRs, and registration processes. Source: Revenue Cycle Management: A Best Practices Toolkit, reprinted with permission For more information visit: http://www.hcmarketplace.com/prod-4003.html
Use this sample pneumonia query form to ensure accurate data reporting for your facility or practice. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-1047.html
Disseminate this list to your coding staff so that they may track physician usage of unapproved abbreviations. Source: Ongoing Records Review, Fifth Edition: A Guide to The Joint Comission Compliance and Best Practices, reprinted with permission. For more information visit: http://www.hcmarketplace.com/prod-5043.html.
