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By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor Editor’s Note: This is the final installment in a four-part series that examines physician documentation issues as seen by an auditor. Click here to read part one: Auditing Issues Uncovered in Physician Documentation: Part I Click here to read…
By Marisa MacClary for For the Record The only way hospital clinical documentation improvement (CDI) and coding staff may compliantly clarify physician documentation for the purpose of accurate coding is to query the physician. The physician query process is essential to ensure accurate quality scores and proper reimbursement. However, most CDI specialists, coders, and physicians…
By Erica E. Remer, MD, FACEP, CCDS for ICD10 Monitor Some providers hesitate to use the word “abuse” preferring, instead, to use non-accidental trauma (NAT). Despite what revenue cycle may believe, clinical documentation is not solely for billing. One of the biggest problems with imprecise, nonspecific diagnoses which lead to unspecified codes or, even worse,…
By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM for ICD10 Monitor CDI, when properly performed, supports the ancient physician oath, “First, do no harm.” Clinical Documentation Improvement Specialists(CDISs) play a vital role in the overall scheme of healthcare delivery through affecting measurable meaningful improvement in the quality, completeness, and accuracy…
By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor Physician documentation issues during an audit go beyond CDI. The issues are the chief complaint and HPI. Editor’s Note: This is the second piece in a four-part series that examines physician documentation issues as seen by an auditor. Click here…
By Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer for ICD10 Monitor Ten strategies for avoiding burnout are provided by the author. On any given day, if you walked into my home office, you might think you were in a spa. The walls are painted a soothing aqua color (at least, I think it’s soothing),…
Article by Susan Richards Morgan, CCS, CPHQ, CPC, CDEO, CRC, CPMA, CEMC, CPC-I. This article was originally published on the A Journal of AHIMA Blog on April 25, 2018 and is republished here with permission. Currently, most clinical documentation improvement (CDI) programs have been developed inside hospitals with an inpatient focus. Medicare generally expects an inpatient admission to need two…
By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor Physician documentation issues during an audit go beyond CDI. EDITOR’S NOTE: This is the first in a four-part series that examines physician documentation issues as seen by an auditor. One of the services I offer, aside from coding…
By Chuck Buck for ICD10 Monitor EDITOR’S NOTE: Opinions expressed by contributors are their own. Following the sea of knitted pink hats worn by some of the hundreds of thousands of women who took to the streets in cities across the country and around the world in January 2017 to stand up for women’s rights,…
Article by Elena Miller, MPH, RHIA, CCS. This article was originally published on the Journal of AHIMA on April 11, 2018 and is republished here with permission. Thinking back on the days when it became clear that the ICD-10 classification system was definitely going to be implemented, the Gold Rush of 1849 comes to mind. There was money…