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By Kat Jercich ofr Healthcare IT News A recent article in Health Affairs called the electronic health record an “underrated medium” for improving care and pushed for the standardization of structures for documenting disabilities. “In medical school, we spend a lot of time learning how to take a patient’s medical history. We practice asking specifically worded questions…
From the ACDIS CDI Blog Because every chart is coded before being sent to payers, it’s important that CDI specialists have a working knowledge of code sets and coding rules. The inpatient prospective payment system (IPPS) final ruling, traditionally updated annually, has been changed to update twice a year on April 1 and October 1 beginning…
By Angela Lima, BS, CCS, CDIP, CIC, COC for For the Record Libman Education’s survey found that 87% of respondents plan to increase their coding expertise. As you read this article, you’re probably sitting in your home office, drinking your third (or fourth) cup of coffee, and perhaps even wearing your favorite pair of slippers. That’s…
From For the Record AHIMA and the Association of Clinical Documentation Integrity Specialists (ACDIS) released a new white paper that examines how rapid advancement in health care technology is driving changes to the practice of clinical documentation integrity (CDI). CDI is critical to the usability of medical data and ongoing efforts to improve patient care. New technologies, such as artificial…
For ACDIS CDI Blog Q: I’ve been told that if there are clinical indicators to support that chronic kidney disease (CKD) is the etiology of a patient’s hypertension, a code from category I15 would be assigned. Code I12 is for hypertensive CKD, isn’t it? So why do we have to use I15 codes instead? What’s…
Georgina Gonzalez for Becker’s Hospital Review Z codes, which are ICD-10-CM codes used to identify non-medical factors that may affect a patient’s health status, are a useful way to track social determinants of health and capture standardized data for Medicare beneficiaries. However, they are underused, with Z codes reported from only 1.59 percent of beneficiaries…
By Jonathan Rubenstein, MD, Mark Painter for Urology Times New and updated codes encompass balloon continence devices, hypospadias Current Procedure Terminology (CPT) codes are continuously being updated. New and updated Category I and III codes will become active on January 1, 2022. In addition, some other Category III codes may be released on July 1 of…
By Marlene Goodwin-Esola, MSN, CV-BC, NE-BC for ACDIS CDI Blog When I first entered the CDI field, I received feedback from someone who left this specialty expressing that her reason for leaving was that CDI was “too sad.” Her rationale was that as a CDI specialist, you might be reviewing a chart of a patient…
By Howard Rodenberg, MD, MPH, CCDS for ACDIS CDI Blog You would think that actually defining something would make it easier to recognize. That statement assumes, of course, that you can actually define what you’re trying to see. (I’m reminded of Justice Potter Stewart’s quote on obscenity, “I shall not today attempt further to define…
By Howard Rodenberg, MD, MPH, CCDS for ACDIS CDI Blog I know this will come as a shock to my many (two) readers, but I’m not quite as perfect as I make myself out to be. I, too, have character flaws. One is that I ask questions. A lot of questions. I do so in…