Clinical Documentation

How hospitals can use Z codes to track social determinants of health

Georgina Gonzalez for Becker’s Hospital Review Z codes, which are ICD-10-CM codes used to identify non-medical factors that may affect a patient’s health status, are a useful way to track social determinants of health and capture standardized data for Medicare beneficiaries. However, they are underused, with Z codes reported from only 1.59 percent of beneficiaries…

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Watch for these urology-related CPT codes this January

By Jonathan Rubenstein, MD, Mark Painter for Urology Times New and updated codes encompass balloon continence devices, hypospadias Current Procedure Terminology (CPT) codes are continuously being updated. New and updated Category I and III codes will become active on January 1, 2022. In addition, some other Category III codes may be released on July 1 of…

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Certain ICD-10 Codes Often Precede Multiple Sclerosis Diagnosis

For Health Day FRIDAY, June 25, 2021 (HealthDay News) — Certain International Classification of Diseases (ICD), Tenth Revision (ICD-10) codes are recorded more frequently before the initial diagnosis in patients with multiple sclerosis (MS) compared with patients with other autoimmune diseases or individuals without these diseases, according to a study published in the June 15…

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ACDIS tip: Pneumonia documentation

By Kathryn Fallah from ACDIS CDI Blog According to the World Health Organization , pneumonia is a form of an acute respiratory infection that inflames the lungs. When CDI professionals review the record and ensure that the documentation of pneumonia is accurate and complete, they can impact reimbursement, risk of mortality scores, and risk adjustment. There are…

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Nursing leaders share strategies for reducing documentation burden

By Kat Jercich for Healthcare IT News The root causes of nursing burnout are varied – as are potential solutions for it. However, given that nurses are frequently responsible for clinical documentation, it’s perhaps not surprising that reducing documentation burden is frequently cited as a key strategy for fighting burnout. Whether it’s through more in-depth electronic health record…

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Chart Conundrums: Queries: Moving Beyond Business as Usual to Identify Learning Opportunities

By Clarissa Barnes, MD for For The Record While often said in jest, my dislike of getting queries delivered to my inbox is (at least indirectly) 100% responsible for my work as a physician advisor. Queries were an intrusion in my otherwise organized workflow. It seemed like my only option was to keep answering them…

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