Q: We recently had a situation where a patient was admitted for syncope workup and all the workups were negative except for incidental findings of AKI. The physician documented “AKI likely 2/2 hypovolemia. Treatment focus is to trend creatinine levels...Read More »
by Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS
Coding reviews provide an opportunity for you to conduct a thorough compliance review that not only addresses other components of the coding process but also the integrity of the patient’s record.Read More »
Some words are just fun. Fun to say, fun to spell, fun to use. One of those words, in my opinion, is quiver. Say it out loud. “Quiver, quiver, quiver.” You can’t help but smile.Read More »
The evaluation and management (E/M) section of the Current Procedural Terminology (CPT®) manual is divided into broad categories such as office visits, hospital visits, and consultations. E/M code assignment consists of seven...Read More »
Many organizations have HCC tools built into their CDI software or EHRs that can help them capture HCCs. When providers click on a diagnosis or a condition, the tool will mark whether the diagnosis is an HCC. Other technology can extract pharmacy data, lab data, other diagnoses, and the problem...Read More »
Even if the treating physician does not immediately document “acute respiratory failure” in the pediatric patient’s record, looking for specific wording and indicators can help support a CDI query to bring that diagnosis in—provided it is appropriate for that patient during that encounter.Read More »
