Q: Is it appropriate to query whether a pressure ulcer was present on admission (POA) if it was not documented until later in the admission?Read More »
Generally speaking, developing consistent query policies and procedures for both coding and CDI staff helps keep everyone in compliance with coding regulations. Similarly, work with clinicians, CDI specialists, and coders as often as...Read More »
By Laurie L. Prescott, MSN, RN, CCDS, CDIP, CRC, and Sharme Brodie, RN, CCDS
The goal of the risk-adjustment model applied to Medicare Advantage plans is for Medicare to provide more accurate payments to the plan administrators to compensate for the care provided.Read More »
After shadowing teammates, try tandem record reviews where your mentor, manager, or other CDI staff member reviews the record first and then turns the record over to you to let you try your hand at it. Then compare notes. Also...Read More »
By Laurie L. Prescott, MSN, RN, CCDS, CDIP, CRC, and Sharme Brodie, RN, CCDS
There are a number of risk-adjustment models used in healthcare which affect reimbursement as well as quality of care reporting metrics. Each model has its own nuances, but all employ ICD-10-CM diagnosis...Read More »
Q:Our coders are having trouble determining how much clinical evidence to cite in our queries. Is there a general rule for how much to include?Read More »
