An emergency department (ED) physician diagnosed a patient with pneumonia. He was concerned about a possible nosocomial etiology given the patient’s recent hospital discharge for problems related to atrial fibrillation. Because the patient’s Pneumonia...Read More »
MLN Matters article SE1121 emphasizes that coders must consider all documentation from licensed treating physicians and attending physicians when assigning a principal diagnosis. It states:
“The emergency room report, history and physical (H&P),...Read More »
The bane of many CDI specialists’ existence is trying to get physicians to buy into good documentation practices. But a recent notice issued by TrailBlazer Health Enterprises, LLC, put in about as plain words I’ve seen that contractors are now going to be comparing Part A (hospital) with Part B...Read More »
As the healthcare industry prepares for a system that rewards value through high quality and efficiency of care, the emphasis on patient safety as a principal priority has become more important than ever, reflected clearly in the responses across the board...Read More »
On December 7, CMS published a final rule in the Federal Register that will give qualified organizations such as employers and consumer groups access to data to help them identify high quality healthcare providers or create online tools to help consumers make educated healthcare choices...Read More »
While CDI and coding staff members are well versed in assigning a principal diagnosis, they are often less adept at incorporating the concept of medical necessity into their practices, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS. Coders tend to simply code what'...Read More »
