CDI

Guest post: Patience required for onboarding and mentoring new CDI staff

By Sonja Racke, RN, BSBM, CPC, CRCR for the ACDIS CDI Blog How many of you remember the nursing days of “see one, do one, teach one?” Of having Nurse Wretched (not Ratchet) hanging over your shoulder while inserting your first Foley catheter in a female grumbling “just look for the blinking eye” and then…

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How CMS final rule will impact E/M coding and documentation requirements

By Ben Howard for Med City News This year ushered in many changes affecting reimbursement for healthcare providers, but few are as important as the new Physician Fee Schedule from the Centers for Medicare & Medicaid Services (CMS) and the updated coding guidelines for Evaluation and Management (E/M) services from the American Medical Association. For…

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ACDIS tip: CDI specialists use legal, coding, and clinical knowledge

By Kathryn Fallah and Karla Accorto for ACDIS CDI Blog CDI is a mix of three categories blended into one, according to Dawn Valdez, RN, LNC, CCDS, CDIP, CDI education specialist with ACDIS in Middleton, Massachusetts. These three categories are: Legal Coding/billing Medical/clinical The legal category deals with query writing, ethics/compliance issues, and finances. Coding and billing…

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Busy ED Environment Breeds Documentation Lapses

By Elizabeth S. Goar for Becker’s Hospital Review When it comes to emergency department activities, documentation doesn’t jump immediately to mind. Far from it, in fact, but that doesn’t mean it’s not vital to an organization’s financial well-being. With emergency department (ED) visits climbing steadily, along with case acuity and complexity, it’s a service line…

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Guest post: Identifying the source of truth

By Howard Rodenberg, MD, MPH, CCDS for ACDIS CDI Blog Many are familiar with the scene from A Few Good Men where Jack Nicholson’s old-school marine tells Tom Cruise’s younger antagonist, “You can’t handle the truth!” My favorite application of that same line comes from Carl Reiner and Mel Brooks’ 2000-Year-Old Man: “You have some kind of thing…

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It’s Time for Coders to Get ‘With’ It

By Lori Amende, RHIA for For the Record Starting in October 2016, coders began to see a shift in how the key word “with” should be applied in the ICD-10-CM classification system. Since then, additional guidance has been provided to help further clarify this coding convention, including some exceptions to be aware of. In this…

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AMA adds CPT codes for J&J COVID-19 vaccine

Katie Adams for Becker’s Hospital Review The American Medical Association on Jan. 19 published three Current Procedural Terminology codes for the COVID-19 vaccine being developed by Johnson & Johnson. The codes allow for better tracking and data reporting by distinguishing the vaccine from others. The AMA published the new CPT codes so that electronic systems throughout the…

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25 statistics on medical coder salaries

By Laura Dyrda for Becker’s Hospital Review The average salary for medical coding professionals varies by location, practice setting and credential. The American Academy of Professional Coders conducts an annual survey to gather information about coder salary and publishes the report on its website. Here are 25 statistics about 2019 salaries, the most recent data available. By…

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