CDI - ICD10monitor

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Why the Highmark decision—since rescinded—was wrong about medical decision-making relative to medical necessity.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…
Questions abound when reporting critical care services.Reporting Adult Critical care can be complicated. It is not only the coding but the rules and that go along with critical care.  Many questions come up when reporting critical care services. You would think it would be fairly straightforward since there are only…
Chronic conditions are the driving force in determining healthcare outcomes and costs in today’s value-based world, hence the interest in the Hierarchical Condition Category (HCC) coding payment model. Coding chronic conditions and co-morbidities is becoming increasingly critical as the healthcare landscape shifts toward value-based care. Value-based care attempts to advance…
Answers to listeners’ questions posed during last week’s edition of Talk Ten Tuesdays are provided here by the author. There is a disconnect among coders and clinicians regarding the concept of “chronic” conditions. All clinicians have interviewed a patient who denies any past medical history, but when confronted with their…
Understanding when and how to use clinical documentation integrity internal clinical guidelines (CDI-ICGs) Clinical policies, clinical practice guidelines, best practice advice: there are numerous ways to refer to written recommendations designed to spell out how best to diagnose and treat patients based on the most current evidence. These are developed…
Healthcare quality and data come from clinical documentation.Bricks and mortar are the foundation of many a structure. Clinical documentation and coding are similar, as they are also the supportive building blocks in healthcare and can be thought of as foundational as well. In healthcare, over the past 25-30 years we’ve…