Integrity means moving from a retroactive, transactional approach to one that documentations patient care. There is much discussion and movement in the clinical documentation improvement (CDI) industry regarding using the word “integrity” in describing the discipline. In perusing the Internet for ...
Coders must ensure documentation supports the service, either moderate sedation or MAC. Coding moderate sedation (or conscious sedation) and monitored anesthesia care (MAC) is not difficult; however, distinguishing what the services provided are and deciphering conflicted information about which ...
Address documentation and coding issues up front, rather than correct them later. Coders have had many challenges throughout the years. When I started in the industry, we did not submit claims electronically; they were submitted on paper and we used an IBM Selectric Typewriter to complete what ...
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Coders are encouraged to query if not sure.The ratio of observed-to-expected deaths is considered a measure of hospital quality. Recording accurate metrics depends on capturing all relevant diagnoses to optimize the expected mortality denominator. The explanatory variables groupings of mortality ...
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- Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSSCesar M Limjoco, MDChuck BuckDeborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement PractitionerDenise M. Nash, MD, CCS, CIMErica E. Remer, MD, FACEP, CCDSEvan M. Gwilliam, DC, MBA, BS, CPC, CCPC, CCCPC, NCICS, CPC-I MCS-P, CPMAGlenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAMGloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS TrainerHolly Louie, RN, BSN, CHBMEJoseph C. Nichols, MDKim Carr, RHIT, CCS, CDIP, CCDS, AHIMA-Approved ICD-10-CM/PCS TrainerKristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS TrainerLaurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS TrainerMark SpiveyMichelle M. Wieczorek RN RHIT CPHQ
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