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By Clarissa Barnes, MD for For The Record While often said in jest, my dislike of getting queries delivered to my inbox is (at least indirectly) 100% responsible for my work as a physician advisor. Queries were an intrusion in my otherwise organized workflow. It seemed like my only option was to keep answering them…
By Sonja Racke, RN, BSBM, CPC, CRCR for the ACDIS CDI Blog How many of you remember the nursing days of “see one, do one, teach one?” Of having Nurse Wretched (not Ratchet) hanging over your shoulder while inserting your first Foley catheter in a female grumbling “just look for the blinking eye” and then…
By Ben Howard for Med City News This year ushered in many changes affecting reimbursement for healthcare providers, but few are as important as the new Physician Fee Schedule from the Centers for Medicare & Medicaid Services (CMS) and the updated coding guidelines for Evaluation and Management (E/M) services from the American Medical Association. For…
By Cynthia Raymond, RN, MSN, CPC, COC, CCDS, ACM-RN for ACDIS CDI Blog CDI specialist’s work can often be tapered down to two categories of work. One category is concurrent stay reviews where CDI makes efforts to ensure that the medical record is accurate and compliant before final coding. The second category of work is…
By Kathryn Fallah and Karla Accorto for ACDIS CDI Blog CDI is a mix of three categories blended into one, according to Dawn Valdez, RN, LNC, CCDS, CDIP, CDI education specialist with ACDIS in Middleton, Massachusetts. These three categories are: Legal Coding/billing Medical/clinical The legal category deals with query writing, ethics/compliance issues, and finances. Coding and billing…
By Elizabeth S. Goar for Becker’s Hospital Review When it comes to emergency department activities, documentation doesn’t jump immediately to mind. Far from it, in fact, but that doesn’t mean it’s not vital to an organization’s financial well-being. With emergency department (ED) visits climbing steadily, along with case acuity and complexity, it’s a service line…
By Howard Rodenberg, MD, MPH, CCDS for ACDIS CDI Blog Many are familiar with the scene from A Few Good Men where Jack Nicholson’s old-school marine tells Tom Cruise’s younger antagonist, “You can’t handle the truth!” My favorite application of that same line comes from Carl Reiner and Mel Brooks’ 2000-Year-Old Man: “You have some kind of thing…
By Lori Amende, RHIA for For the Record Starting in October 2016, coders began to see a shift in how the key word “with” should be applied in the ICD-10-CM classification system. Since then, additional guidance has been provided to help further clarify this coding convention, including some exceptions to be aware of. In this…
By Howard Rodenberg, MD, MPH, CCDS for ACDIS CDI Blog Nobody likes being proved wrong, but it’s not always a bad thing. It’s probably okay to be proven wrong when you think it’s a good idea to feed a shark by hand, or to drink a few beers and then tell your buddies you can…
Katie Adams for Becker’s Hospital Review The American Medical Association on Jan. 19 published three Current Procedural Terminology codes for the COVID-19 vaccine being developed by Johnson & Johnson. The codes allow for better tracking and data reporting by distinguishing the vaccine from others. The AMA published the new CPT codes so that electronic systems throughout the…