Q: In terms of coding blood transfusions, does the documentation of which intravenous (IV) site used has to come from the physician in the progress note, or can this particular information be extrapolated from nursing notes, orders, etc.? Read More »
Q: Is there guidance on reviewing a record, such as an operative (OP) note, that has not been signed by a physician? I am at a facility that allows coding from unsigned transcriptions. I was always told that the information needs to be confirmed by a signature as valid before including...Read More »
Q: CMS released guidance this summer about not auditing or counting errors for the specificity of an ICD-10-CM code. CMS is not going to count the code as an error as long as the first three digits are correct. Does this apply to medical necessity diagnoses and edits. Read More »
As you plan your itinerary, we are interviewing a handful of speakers to give you a feel for the sessions. This week, we spoke with Susan Edamala RN, MSN, CCRN, CDI specialist at the University of Illinois in Chicago, who, along with Karl Kochendorfer, MD, FAAFP, will present “...Read More »
Q: I am having trouble with the procedure (PCS) coding for a perineal laceration repair. Some sources state that the correct code uses the perineal anatomic region, not muscle repair. Would you please clarify the correct ICD-10-PCS code for a second degree obstetrical (perineum)...Read More »
As you start to plan your itinerary, we’re interviewing a handful of our speakers to give you a preview of the sessions and what you can expect at this year’s event. This week, we spoke with Carrie Norwood, RN, BSN, CPN, CDI Specialist at Children’s of Alabama in Birmingham, who...Read More »
Q: How can our CDI team prepare for potential productivity losses post-ICD-10 implementation, specifically regarding procedure codes (PCS)? Should we consider hiring additional staff, or staff with a surgical background?Read More »
Q: Is there an industry standard metric goal for CDI specialist reviews of Medicare cases? Should a CDI team strive to review, for example, 80% of all Medicare discharges in a given month?Read More »
