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By Michelle M. Wieczorek RN RHIT CPHQ for ICD10 Monitor In this article, the author examines the implications for the capture of Hierarchical Condition Codes (HCCs) in the inpatient setting. By now, most clinical documentation improvement (CDI) programs have an appreciation for the use of cases reflecting how Hierarchical Condition Codes (HCCs) impact upon quality…
By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer for ICD10 Monitor 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. As with ICD-10,…
By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor 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 commonly known as AMI, had a definition change when the nation’s healthcare system…
By Angie Comfort, RHIA, CDIP, CCS, CCS-P for For the Record In October 2017, the Department of Health and Human Services (HHS) declared a public health emergency to focus on the opioid crisis. Analyzing data from 2000 to 2015, HHS estimated that 91 Americans had died of opioid overdoses each day, and the numbers have…
By Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner for ICD10 Monitor 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…
Three questions to consider when evaluating a clinical documentation improvement program. By Lisa A. Eramo, MA for For the Record Review the record. Query the physician. Obtain the diagnosis. Repeat. Does this clinical documentation improvement (CDI) workflow sound familiar? Productivity is the hallmark of a good program. Or is it? On the surface, CDI specialists…
By Laura Dyrda for Becker’s ASC Review Professional coders are more likely to see compensation increases when they achieve higher credentials, and the percent increase in year-over-year compensation is higher for the most-credentialed individuals, according to the AAPC 2016 Salary Survey. The survey was completed by 9.2 percent of AAPC membership, and 2.2 percent hold…
For HIM and CDI professionals, 2018 looks to offer a gift of the tremendous opportunity for success. By Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS for ICD10 Monitor For movie buffs, the film Darkest Hour offers a tremendous view into the early days of World War II, when the fate of Western Europe hangs on…
By Erica E. Remer, MD, FACEP, CCDS for ICD10 Monitor Dieticians’ findings must find their way into the medical record to achieve proper care and coding. Diagnosing malnutrition is not diving for dollars. Malnutrition – and I am specifically talking about undernutrition today – is a common but frequently unrecognized problem that leads to difficulty…
By Angie Dibble, RHIT for For the Record Remember when we thought of medical charts as inanimate objects, safely tucked away on a dusty shelf in a paper mill known as “Medical Records”? In my prior life, the one I innocently enjoyed before working in health information, I believed all medical charts were somehow pure…