CDI specialists typically review inpatient records to obtain specificity related to principal and secondary diagnosis. As a profession, such staff combine clinical knowledge with coding, billing, and documentation experience. Although not as prevalent as inpatient efforts, outpatient CDI is a...Read More »
At least a few members of Congress heard the complaints of constituents regarding the “2-Midnight” rule included in the 2014 IPPS Final Rule, and more than 100 House Representatives signed a letter to CMS urging the agency to delay the rule by at least six...Read More »
In two recent findings from the Office of the Inspector General (OIG), improper documentation may have led to inaccurate claims submission and associated payments....Read More »
There are many articles about the enhanced documentation required in ICD-10-CM. However, the real challenge will be ICD-10-PCS. It is a completely new code set and is not used in any other country than our own. ICD-10-PCS does not include...Read More »
CMS has been releasing ICD-10 National Coverage Determination (NCD) “omnibus” transmittals since September 2012, which gives providers some information about CMS’ coverage policies moving forward. NCDs are only part of the picture. On September 6, CMS...Read More »
Q:The primary physician documented subacute cerebral infarction and I am wondering whether I should code this to a new cerebral vascular accident (CVA) or not since the term “subacute” doesn’t really fall anywhere.
