I almost didn’t become a nurse. I was almost booted out of nursing school. For alleged transgressions too ridiculous to describe, a petty instructor failed me in my pediatrics clinical. While the director basically conceded that the...Read More »
While the majority of CDI programs report to the director of HIM, a good number (27%, according to the 2010 CDI Program Benchmarking Report) fall under the supervision of the director of case management (CM). CDI programs that report to CM face a number of...Read More »
Well, it’s happened again. Because of inappropriate definitions of new disease codes, Medicare could take a massive hit financially and get into...Read More »
I feel like saying a little bit about why we do what we do, or at least why I do what I do. In the course of my 26-year nursing career, I worked in many venues. For about 14 years, I was an ICU nurse, and although many patients have...Read More »
If you are from the South, football is all that matters. I grew up in Alabama and now live in Mississippi. You have to understand that this time of year all we care about is tailgating and football. So my advice is to weave an analogy...Read More »
Documentation is central to accurate coding and reimbursement. It justifies treatment, supports the diagnosis, and captures patient severity and acuity. None of that comes as a surprise to coders, who often have to deal with documentation shortcomings.
Q:Some of our physicians have started documenting “aspiration without pneumonia.” When I questioned one of them about it, he said the patient had acid pulmonary syndrome/Mendelson’s syndrome. When I told the physician that this condition maps to the code for pneumonia,...Read More »
Many CDI specialists don’t spend a lot of time working with obstetric (OB) records, or may even ignore them altogether, principally because of the ICD-9-CM Chapter 11 coding guideline that basically says that pregnancy overrides...Read More »
