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By by Trey La Charité, MD, FACP, SFHM, CCDS for ACDIS CDI Blog People are human. This goes for clinicians, coders, and for CDI personnel. Mistakes happen. If left unchecked, however, mistakes become habits. Effective CDI programs understand this and take appropriate steps to ensure occasional mistakes don’t become recurring bad habits. Since the structure and…
By Cheryl Ericson, MS, RN, CCDS, CDIP for For the Record When discrepancies occur, the ensuing reconciliation process serves as a prime opportunity to educate CDI and coding staffs. Reconciliation rates monitor both clinical documentation improvement (CDI) and coding proficiency, a key performance indicator. However, many in leadership positions overlook the importance of trending reconciliation…
By Sheila Duhon, MBA, RN, CCDS, A-CCRN, CCS for ACDIS Blog It’s often a challenge for CDI specialists to obtain precise documentation of anemia in the medical record. A hospitalist once asked me why I sent him a query for anemia because since he would treat it the same way no matter what, he wanted…
By Angie Stewart for Becker’s ASC Review Insurers may wrongly deny a claim and hope providers don’t notice it’s actually a covered service, according to medical coding and billing specialist Steven Verno. Mr. Verno shared the following tip for appealing a non-covered service on LinkedIn: “You need proof that the insurance company is wrong. The…
By Atul Gawande for The New Yorker On a sunny afternoon in May, 2015, I joined a dozen other surgeons at a downtown Boston office building to begin sixteen hours of mandatory computer training. We sat in three rows, each of us parked behind a desktop computer. In one month, our daily routines would come…
By Tracy Boldt, RN, BSN, CCDS, CDIP, and Ellen Jantzer, RN, MSN, CCDS, CCS, CRC for ACDIS Blog The rules of compliant query practice do not change based on the setting. We must consider query construction and wording of provider communication with the same eye for compliance as we have traditionally done in the inpatient…
By Jackie Drees for Becker’s Hospital Review Vishal Bhatia, MD, chief medical information officer at RCCH HealthCare Partners in Brentwood, Tenn., discusses the evolution of his role as CMIO and how artificial intelligence, natural language processing and voice recognition technologies can improve healthcare. Responses are lightly edited for clarity and length. Question: How has your role…
With its proposed changes to payments and documentation for office visits, the agency is effectively forcing providers to reckon with a longstanding, oft-disputed problem. By Tony Abraham for Healthcare Dive Most healthcare players agree the evaluation and management billing codes used by CMS need an overhaul, but few like the manner to do so proposed…
By Karla VonEschen, CPC for For the Record Correct use of unlisted CPT codes is one of the more confusing aspects of CPT coding for both coders and physicians alike. Although unlisted codes are used only when no code exists to accurately describe a procedure or service, these codes serve an important purpose. With advancements…
By Chris Simons MS, RHIA for ACDIS Blog As the coder or CDI specialist reviews the documentation, he or she will identify opportunities to clarify diagnoses or even to identify conditions that were not previously documented but may be possible given the patient’s presentation. By querying the physician while the patient is still in the…