Clinical & Coding

Q: If I document a wound at Stage 3 with no CC or MCC, do I also need to assign a present on admission (POA) status?
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by James S. Kennedy, MD, CCS, CDIP

Even though we now have a new president of the United States who vowed to abolish the...Read More »

Nearly half of the death certificates reviewed by the Centers for Disease Control and Prevention from 2009 to 2012 listed the cause of death...Read More »

A Comprehensive Error Rate Testing (CERT) study showed insufficient documentation caused the most improper payments for facet joint injections,...Read More »

Since the advent of electronic medical record (EMR) systems, CDI professionals have known that physician copy and paste errors pose a threat to...Read More »

The 2017 updates to ICD-10-CM included many additions to the digestive system diagnoses, especially with codes for pancreatitis and intestinal...Read More »

Intensive care units are expensive, invasive, and supposed to be reserved for the sickest hospital patients, but more than half the time, they're...Read More »

The 2017 Surviving Sepsis Campaign (SSC) guidelines to be published in the March 2017 issue of...Read More »

Q: If a complication was unavoidable, and has been documented as such, is that good enough reason to not code it? We wouldn’t...Read More »