Document it right on the front end; avoid fighting a denial on the back end I was recently asked about a post from Hospital Performance regarding acute respiratory failure and airway protection (https://soundphysicians.com/blog/2018/06/20/from-the-appeals-desk-acute-respiratory-failure-part-1-2/), and I wanted to expand on what the author, Dr. Hesham Hassaballa, wrote. A key point is…

The industry knows that focusing more on SDoH reduces costs. Healthcare costs and coding have been married over 35 years, since the Social Security Act was amended to include a national Diagnostic Related Groups (DRG)-based hospital prospective payment system for all Medicare patients.  The culture of the healthcare industry changed…

An inspiring story about rebranding a facility’s CDI department To raise a torch to the strength of women working in healthcare I must share an introductory story on the transformation of a revitalized CDI Department that has pursued success through the strength of 23 women, and the celebrations are taking…

Physician documentation issues during an audit go beyond CDI. The issues are the chief complaint and HPI. Editor’s Note: This is the second piece in a four-part series that examines physician documentation issues as seen by an auditor. As I discussed in the first portion of our series on physician…

CCD is when the typical and customary documentation of a condition does not line up with the available codes or the indexing. Last week, I discussed the Type 2 MI issue. This week, I will address the higher-level problem of the “coding-clinical disconnect,” which I am going to refer to…

HIM coding can play a part in stopping the abuse and neglect of children Marking April as National Child Abuse Prevention Month, we note that the Center for Disease Control (CDC) reports that child abuse and neglect are significant public health issues in the United States. The CDC reports that…

It is highly recommended to self-audit first, internally, with qualified staff. EDITOR’S NOTE: This is the first in a four-part series on the importance of passing or failing an audit and avoiding being a red-flag to payers. One of the services I offer, aside from coding and billing education, is…

Type 2 MI is not a coding construct.  I received some correspondence regarding my Type 2 myocardial infarction article last week which prompted me to ponder the coding-clinical disconnect. Let us address the Type 2 MI concerns this week, and next week, I will tackle the broader picture. Historically, the…

This disease of the brain is the most common neurological disorder Parkinson’s awareness is being addressed tomorrow, April 11, as “World Parkinson’s Day,” also making April national Parkinson’s awareness month here in the U.S. As a neurodegenerative disease of the brain, which impacts an individual’s motor function, Parkinson’s Disease (PD)…

Review your payer policies when performing these services. Pain management coding can be tricky.  Trigger point injection therapy is a common procedure performed by pain management specialists, orthopedic surgeons, physical medicine and rehab and other specialties. Trigger point injection therapy is used for the treatment of myofascial pain syndrome (MPS).…