In Coding
Mar 29th, 2019
Clinical documentation improvement (CDI) is a process that continually seeks to answer, “How best can maximize the integrity of the medical record?” Although the goal of CDI is always the same—to provide a complete and accurate picture of a patient’s medical condition(s) and the care they receives—the means to achieve that goal are often specific ...
In understanding each other’s role in healthcare reimbursement, coders and CDI specialists make a dynamic duo. In healthcare, we can no longer work in silos, separate from each other, doing our own thing, unaware of what other staffers are doing. We must work collaboratively, as a team that extends past our own departments. Value-based healthcare ...
In Billing
May 25th, 2018
Spondylolisthesis is a perfect example of why ICD-10 requires improved clinical documentation. In ICD-9, Acquired spondylolisthesis was reported with one code, 738.4. In ICD-10, there are 14 codes: M43.00 Spondylolysis, site unspecified M43.04 Spondylolysis, thoracic region M43.05 Spondylolysis, thoracolumbar region M43.06 Spondylolysis, lumbar region M43.07 Spondylolysis, lumbosacral region ...
Help physicians fill in the missing information when they use visual cues to determine a diagnosis. Most coders are familiar with the coding and documentation guidelines required to support the management of hierarchical condition categories (HCCs); for certain conditions, however, physicians may use visual cues to decide whether the patient’s diagnosis is appropriate. This can ...
Their revenue and reputation are on the line. It has become clear that physicians are caught in a cycle of poor documentation because that is what they are taught by their peers. Coding professionals have an opportunity to bring it to an end by promoting and teaching a culture of proper medical record-keeping, which accurately ...