Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS; Laurie L. Prescott, RN, MSN-Ed, CCDS, CDIP, discuss key elements in ICD-10-PCS that must be present in the documentation for accurate code assignment—there are no characters that stand for “the documentation doesn’t say.”
Mary Kay Brooks, RN, MSN, CPHQ, offers strategies to address documentation opportunities and standardize processes for improvement for both PSI 15 and PSI 90.
Victor Freeman, MD, MPP explains the need for evidence-based diagnostic criteria in the ED, why sepsis, acute renal failure, and acute respiratory failure are so poorly documented in the ED, and why capturing these diagnoses is critical for ensuring/promoting diagnosis capture in the rest of the...
Kelli A. Estes, RN, CCDS and Cesar A. Limjoco, MD encourage an alignment between CDI specialists and coders to understand the need for capturing conditions based on the clinical truth instead of jumping at indicative numbers.