CDI - ICD10monitor

Coding leadership routinely benefits from learning team members' strengths and weaknesses and adjusting plans to match. I began working with Novant Health in 2011, when I used the phrase “best of the best” for my team. This was our department’s vision for our future, and it is a standard we…
The new classification is designed as a database and has up to 13 dimensions. The World Health Organization (WHO) will be releasing the 11th Revision to the International Classification of Diseases, or ICD-11, this May. The WHO and many of its 194-member countries have been working on this since 2007.…
There is a definite need for outpatient CDI programs – provided that hospital administration takes the right approach to its development and implementation. Interest in outpatient clinical documentation integrity (CDI) programs is multiplying as more and more hospital services are moving to the outpatient setting and healthcare reimbursement models are…
Official guidance on ICD-10-CM coding raises questions regarding how to document cardiac care. The first step in choosing the proper ICD-10-CM code is reading the medical documentation to identify the diagnosis the provider has documented and confirmed. If there is no confirmed diagnosis, look for the sign or symptom that…
There are now five types of myocardial infarction (MI) code categories, and the author describes these new options and how they will impact reimbursement. For cardiology, the focus of ICD-10 is generally on increased specificity and documenting the downstream effects of the patient’s condition. Acute myocardial infarction, or what is more…
Coding the flu consists of the signs and symptoms of flu, the vaccination, and coding the actual disease and its complications This winter has been a long one for those healthcare workers who have been busy treating flu patients and trying to prevent the flu. On Feb. 7, 2018, the…
If physician training and education on clinical documentation is not done correctly, you might as well not do it at all It is common knowledge that the reason clinical documentation integrity (CDI) programs exist is to bridge the gap between the language physicians speak and what can be accurately captured…
In this article, the author gives a shout-out to auditors for the good work they do. For those of you who are CEOs, CFOs, medical directors, etc., I would like you to take a moment and read the excerpt below, written by a physician representing a facility, paying close attention…
Why the Highmark decision—since rescinded—was wrong about medical decision-making relative to medical necessity. When payers and coders downcode evaluation and management (E&M) notes based on medical necessity, how do they determine what level of history and exam is medically necessary for a particular presenting problem? The answer: subjectively.  What is…
Erica Remer, MD responds to listeners questions from the Talk Ten Tuesday broadcast Jan. 30th.  Since I am out of town on an empty-nesting trip with my husband, I decided to answer the questions we couldn’t get to last week, in writing. When Linda Holtzman and I were bandying about…