For many surgeons, “surgical precision” doesn’t just describe their specificity and prowess in the operating room; it often describes their personality as well. Their fine-tuned accuracy is a point of pride not only in the surgical theater, but in everything they do.Read More »
By Sharme Brodie, RN, CCDS
I know everyone is very excited that the newest AHA Coding Clinic, second quarter 2018, is out and ready for review. The great news is it’s only 27 pages in length, and I know with everything else going on (including that it’s summertime), this...Read More »
Q: If an uncertain diagnosis is only documented by a consultant consistently through the medical record, including in the last progress note, and is left out of the discharge summary, should that diagnosis be coded?Read More »
By Amy Sanderson, MD
The term “dysphagia” has many synonyms used by providers in medical documentation. However, not all of these symptoms are able to describe, with specificity, the real problem so it can be translated into its corresponding code assignment.Read More »
By Sharme Brodie, RN, CCDS
So, the first AHA Coding Clinic for 2018 is out, and I must admit, I was surprised at its length. At only 26 pages, it is one of the shorter editions of late. Some of the questions covered within its few pages, however, were ones I often discuss...Read More »
By Drew Siegel, MD, CCDS
One of the more interesting aspects of CDI is taking on the role of a detective to identify and evaluate clues in the medical record that suggest the presence of an undocumented diagnosis, then using these clues to write a compliant and clinically-...Read More »
By Steve Robinson, MS-HSM, PA-O, RN, SSBB, CDIP
When building a successful proactive clinical documentation approach in any patient care venue—inpatient, outpatient, or professional—the effort of setting up communication dynamics is essential and should certainly be a priority.Read More »
By Lori-Lynne A. Webb, CPC, CCS-P, CHDA, CDIP, COBGC
Back in 2016, I wrote the following synopsis for HCPro about outpatient/office diagnosis reporting, clarifying some of the misunderstood procedural guidelines between inpatient and outpatient services....Read More »
