Q: I am a relatively new CDI specialist in a relatively new CDI program. We learned that we should be examining the health record with an eye toward “what bought the bed.” When we raise this concept to our coders, however, they disagreed with the premise, telling us that such a...Read More »
I became a physician because I enjoy taking care of sick people. In today’s environment, however, I am subject to numerous unanticipated burdens that interfere with my continued enjoyment of that privilege. In discussions with my colleagues, I clearly have...Read More »
Contractors could use a little guidance from CMS to do a better job at reviewing medical records for electronic health record (EHR) problem areas. For example, clues within the progress notes, hand writing styles, and other attributes that help corroborate the authenticity of paper medical...Read More »
Thankfully, some of the documentation and coding issues I have been screaming about over the past 10 years have been heard with the transition to ICD-10.Read More »
Of the nearly 450 respondents to a recent ACDIS website poll, 50% say they conduct pre-payment record reviews, with an additional 7% indicating their facility is considering implementing such reviews in 2014. Of that 50%, 35% of...Read More »
What is the correct code assignment for a diagnosis of postoperative aspiration pneumonia? ICD-9-CM’s Tabular List under code 997.39 provides the following inclusion terms: “Pneumonia (aspiration) resulting from a procedure.” However, the instructional note under category 997 states, “Use...Read More »
Q: We are struggling with how to query physicians regarding complications of procedures or surgeries. For example, a patient was readmitted for a bile leak two weeks after a cholecystectomy. Neither the attending nor the GI consultant ever stated that this was a complication. Can you...Read More »
