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Issue 12, December 1, 2015 - VIEW THE FULL ISSUE
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Latest AHA Coding Clinic for ICD-10 covers orthopedic, cardiovascular coding
Some interesting tidbits of information can be gleaned from the most recent release of the AHA... -
The CDI team's impact on the CMS pneumonia readmission measure
The Hospital Readmissions Reduction Program (HRRP) is a CMS pay-for-performance program that links... -
Neonatal or not neonatal?
The terms "newborn" and "neonatal" have different definitions depending on the... -
Meet the challenges of spinal arthrodesis coding in ICD-10-PCS
Coding for spinal arthrodesis procedures has always been a challenge given the complexity of these...
Issue 11, November 1, 2015 - VIEW THE FULL ISSUE
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Predicting ICD-10 losses and tracking key performance indicators after October 1
After several delays, ICD-10 implementation is finally upon us. The healthcare industry has spent... -
Adding venous thromboembolism to the CDI checklist at your facility
The annual incidence of an initial venous thromboembolism (VTE) event, either a pulmonary embolus... -
Past is present: ICD-10-CM clears some ICD-9-CM issues while others persist
I have been musing recently about things I've written for this journal over the past years. Hard to... -
Training tool: Choose the correct ICD-10-PCS root operations and devices
Use this 10-question quiz to determine how well you understand ICD-10-PCS root operations and...
Issue 10, October 1, 2015 - VIEW THE FULL ISSUE
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Sepsis: Understand clinical presentation and coding strategies for ICD-10
A 12-year-old male developed umbilical discomfort Monday and didn't eat much dinner. On Tuesday, he... -
Have you integrated CMS FY 2016 quality measures into your CDI program?
Each new CMS fiscal year, MS-DRG weight and classification changes in the CMS IPPS final rule are... -
Picking last-minute ICD-10-CM/PCS priorities
Dual coding. Reformatting queries. Educating physicians. Let's face it?the to-do list for ICD-10... -
CMS setting itself up for billions of dollars of wasteful spending in ICD-10
Sometimes people do their homework with setting up a new system, and sometimes they don't...
Issue 9, September 1, 2015 - VIEW THE FULL ISSUE
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Identify ICD-10-PCS MS-DRG shifts
ICD-10 implementation will arrive very soon, and many facilities are putting the final touches on... -
CMS focuses on value over volume in IPPS rule
CMS continued its focus on improving the quality of patient care in the fiscal year (FY) 2016 IPPS... -
More chart review findings: Keep that education coming
Robert S. Gold, MD, discusses educational opportunities for sequencing viral gastroenteritis...
Issue 8, August 1, 2015 - VIEW THE FULL ISSUE
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Identify orthopedic coding challenges
Ask a physician why he or she documents in the medical record and you'll get a variety of answers... -
Details distinguish between Excision, Resection
ICD-10-PCS root operations Excision and Resection differ only in how much of a body part is... -
CMS proposed minor changes to 2-midnight rule
Although CMS did not propose any changes to the 2-midnight rule in the fiscal year 2016 IPPS... -
Identify opportunities from audits
It's great, identifying opportunities to teach. Whenever I do medical record audits, I always look...
Issue 7, July 1, 2015 - VIEW THE FULL ISSUE
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Keep up with Coding Clinic for ICD-10-PCS
With fewer than 100 days until ICD-10-CM/PCS implementation, plenty of questions still remain about... -
Focus on criteria for acute renal failure
Physicians often use the terms acute renal failure (ARF) and acute kidney injury (AKI... -
When acute respiratory failure isn't really acute respiratory failure
Respiratory failure, whether acute or chronic and whether following surgery or not, is one... -
Identify vulnerabilities related to PSI 12
PSI 12 evaluates the hospital's risk-adjusted rate of perioperative deep vein thrombosis (DVT...
Issue 6, June 1, 2015 - VIEW THE FULL ISSUE
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Prepare for increased queries in ICD-10-PCS
ICD-10-CM will still allow coders to report unspecified codes. However, coders will not have that... -
CMS continues focus on quality measures
IPPS proposed rule includes ICD-10 codes, no changes for 2-midnight rule -
Drill down into Patient Safety Indicator 7
In the third part of our series on Patient Safety Indicator 90, we focus on inclusions... -
Accidental laceration criteria misunderstood
Robert S. Gold, MD, highlights areas of confusion involving PSI 15 guidance.
Issue 5, May 1, 2015 - VIEW THE FULL ISSUE
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Focus in on PSI 15 to improve reporting
PSI 15 measures the hospital's risk-adjusted rate of accidental punctures and lacerations. PSI 15... -
ICD-10-CM adds a new concept with underdosing
Take note of the changes and similarities between ICD-9-CM and ICD-10-CM. -
Conflicting documentation: The mechanisms of diagnosis inconsistency
Robert S. Gold, MD, reviews how to identify conflicting documentation. -
Coding Clinic highlights mechanical ventilation, principal procedure sequencing
Take a look at some of the most interesting areas discussed regarding the coding of surgical...
Issue 4, April 1, 2015 - VIEW THE FULL ISSUE
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Refresh your knowledge of CC/MCCs
Even through ICD-9-CM and ICD-10-CM/PCS are currently under a code freeze, coders and CDI... -
Take a high level look CMS' PSI 90
Patient Safety Indicator 90 evaluates hospital performance for defined in-hospital complications... -
Aftercare codes get a makeover in ICD-10-CM
ICD-10-CM will resolve some of the confusion surrounding aftercare codes by using seventh... -
Tension over hypertension as we transition from ICD-9-CM to ICD-10-CM
Robert S. Gold, MD, discusses hypertension in its various forms.
Issue 3, March 1, 2015 - VIEW THE FULL ISSUE
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Simplify coding, CDI concerns for complications
It's not uncommon to see conditions arise in the postoperative period. The question is, are they... -
Get back to query basics
The American Health Information Management Association (AHIMA) and the Association of Clinical... -
Consultants failing with heart failure
Robert S. Gold, MD, explains when to skip the query on heart failure. -
House subcommittee hears from industry stakeholders on ICD-10
On February 11, costs and plans took center stage at the ICD-10 implementation hearing held by the...
Issue 2, February 1, 2015 - VIEW THE FULL ISSUE
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Coding, CDI focus on heart disease differs
Coronary artery disease (CAD) develops when the arteries that supply the blood to the heart muscles... -
Queries can help reflect accurate SOI, ROM
Coding tells a patient's story, based on the narrative the physician provides in his or her... -
Coding Clinic continues to focus on ICD-10-PCS
Many coders and CDI specialists memorized previous Official Guidelines for Coding and Reporting... -
Determine when to code a condition
Coding professionals may inappropriately assign codes from parts of the medical record where the...
Issue 1, January 1, 2015 - VIEW THE FULL ISSUE
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ICD-10-PCS bypass is more than CABG
Coronary artery bypass graft (CABG) procedures are not the only ones coders will report using the... -
Second Quarter advice on PCS coding and documentation
Despite all the uncertainty surrounding the implementation of ICD-10-CM/PCS, the Cooperating... -
Know when to charge for ancillary bedside procedures beyond the room rate
Inpatient coding professionals are used to DRG systems where all of the diagnoses and procedures... -
Know when to ask for more information
Sometimes the physician's documentation is insufficient to represent what the patient actually...