Complication coding is a hot topic among coding, clinical, and compliance professionals. It’s considered to be one of the more challenging aspects of coding. Physicians are hesitant to document post-operative complications, as they negatively affect their quality scores on sites like Healthgrades.com. Hospitals, however, need to be compensated for the…
This is a very exciting time to be in the field of clinical documentation improvement (CDI), with so many emerging opportunities beyond just reviewing for major complications and comorbidities (MCCs) and complications and comorbidities (CCs). CDI programs are growing into so much more than just a mechanism for reviewing documentation…
At this point, most clinical documentation improvement (CDI) programs are well-versed in the topic of malnutrition. New and old programs alike acknowledge that malnutrition is under-documented and that appropriately establishing this diagnosis for the patient can improve severity-of-illness metrics.
Recently I served as a panelist for Talk Ten Tuesdays, ICD10monitor’s weekly Internet program. The program covers a variety of topics, but ICD-10 is its primary focus.   The experience got me to thinking: we are already seeing, ICD-10 can provide us some rich data, and this directly ties to…
“Patient with transaminitis, keep watching labs.” “Patient’s liver enzymes extremely elevated, keep in ICU.” Physicians may have seen these notes before. But transaminitis and “extremely elevated liver enzymes” do not equate to shock liver or acute and subacute hepatic failure without coma. 
ICD-10 went into effect Oct. 1, 2015 and, so far, everything seems to be going pretty well. There are a few areas, however, that continue to give clinical documentation improvement (CDI) specialists and coders headaches. One of these problems is Acute Myocardial Infarction (AMI) documentation. In ICD-10 there is a…
If you don’t read anything else this holiday season, read this. Documentation improvement is at the heart of any successful ICD-10 coding program, and in this article I will highlight eight key areas of focus about ICD-10 and clinical documentation improvement (CDI).
On Oct. 1, 2015, health systems across the country bid farewell to ICD-9 as they transitioned to the International Classification of Diseases’ 10th Revision – ICD-10.
Once in a while, the people who monitor the ICD codes actually listen to the providers of healthcare (rarely, but once in a while). When ICD-10 first came to the fore as an upcoming entity, the major non-trauma issue everybody noted was that code I10, hypertension, eliminated identification of benign…
Lewy body dementia is the second-most common type of progressive dementia after Alzheimer’s disease, and it is captured with ICD-10-CM code G31.83, Dementia with Lewy Bodies. G31.83 is listed in section G31, titled "Other degenerative diseases of nervous system, not elsewhere classified,” and is included in category G31.8, titled "Other…