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Displaying records 1 to 20 out of 7282 results for "diagnosis documented one time".
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SORT RESULTS BY: RELEVANCY | PUBLICATION DATE
Q: How should the diagnosis of urinary tract infection (UTI) and encephalopathy be sequenced,
MARCH 11, 2015
JUSTCODING
Q: How should the diagnosis of urinary tract infection (UTI) and encephalopathy be sequenc
OCTOBER 8, 2014
JUSTCODING
by Megan Herr Muscle weakness is one of the most commonly seen and assigned prim
Q: The physician documented “encephalopathy” in the record of a patient who wa
Heart failure is one of the top MS-DRGs, so Recovery Auditors have focused on identifying
AUGUST 27, 2014
JUSTCODING
By James S. Kennedy, MD, CCS, CDIP The physician documented “encephalopathy&
MARCH 25, 2015
JUSTCODING
Most coders and clinical documentation improvement (CDI) specialists are familiar with the Unifor
JANUARY 14, 2015
JUSTCODING
To accurately interpret and code physician documentation, the HIM department should employ
JUNE 4, 2014
JUSTCODING
by Kirsten Dize Strong documentation is key in home health, and implementation o
Coding guidelines direct to code all documented conditions that exist at the time of the visit an
At ACDIS, it’s no surprise when we hear about clinical documentation improvement efforts
While the new diagnosis code to capture COVID-19 has been in effect since April 1, coders have ru
Becoming a manager for the first time can be an overwhelming experience. You will need a whole ne
NOVEMBER 11, 2019
With the ICD-10 implementation deadline up in the air, hospitals have a bit of extra time
Every patient who is admitted to the hospital has a principal diagnosis—the reason that occ
JANUARY 28, 2015
JUSTCODING
One of the biggest changes in ICD-10-CM is the time frame for reporting an acute myocardial infar
NOVEMBER 5, 2014
JUSTCODING
Q: Is it okay to code a diagnosis if the physician documents two diagnoses using
  Q: Is it okay to code a diagnosis if the physician documents two diagnoses usin
SEPTEMBER 24, 2014
JUSTCODING
OCTOBER 8, 2014
JUSTCODING
JANUARY 28, 2015
JUSTCODING
Q: Should I query for chronic respiratory failure if the documentation indicates the patient
NOVEMBER 20, 2013
JUSTCODING
When a hospice discovers a new ADR, staff should review the time frame for the ADR, assem
By Cheryl Ericson, MS, RN, CCDS, CDIP Many clinical documentation improvement (CDI
JULY 29, 2015
JUSTCODING
MARCH 11, 2015
JUSTCODING
In the rush to complete ICD-10 coding education, documentation improvement, and system updates, H
OCTOBER 21, 2015
JUSTCODING
MAY 6, 2015
JUSTCODING
Put on your deerstalker hat and grab your magnifying glass. It’s time to do our best
The most welcome changes to me are the removal of those coding items, M1011 (Inpatient diagnosis)
Q: I have been asked to build a query for a diagnosis of SIRS and/or sepsis for the following
JULY 29, 2015
JUSTCODING
Q: Can you define equally treated in the selection of principal diagnosis with multiple
MARCH 26, 2014
JUSTCODING
By utilizing the information documented in the record, coders can report the BMI from a dietitian
I am searching for clear, legitimate, documented guidance regarding coding for a verbal o
Q: Sometimes I confuse the secondary diagnosis for the primary diagnosis. Do you have
Is it true that the following documentation is an improper certification statement on our
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician document
SEPTEMBER 3, 2014
JUSTCODING
Insufficient documentation led to approximately 97% of improper payments for kyphoplasty a
JULY 23, 2014
JUSTCODING
A patient presents to the ED with a headache, nausea, and vomiting. The physician documented that
FEBRUARY 25, 2015
JUSTCODING
Q: I have been asked to build a query for a diagnosis of SIRS and/or sepsis for the f
ICD-9-CM includes a diagnosis code to show when a surgeon converts a laparoscopic procedure to an
DECEMBER 3, 2014
JUSTCODING
NOVEMBER 19, 2014
JUSTCODING
Organizations in Florida have one more thing to worry about following a breach of personal inform
Q: Can you code strictly from emergency department (ED) documentation? Can you code from tes
DECEMBER 16, 2015
JUSTCODING
  When a provider fails to document whether a patient diagnosed with monoplegia ha
MAY 13, 2015
JUSTCODING
Editor’s note: This week’s The Inside Story was adapted from one of HCPro
For the first time since ICD-10 coding implementation in October 2015, the application of it in S
NOVEMBER 8, 2019
Choosing the right format will depend on what information is lacking. Queries are not “one
SEPTEMBER 3, 2014
JUSTCODING
We don’t like to talk about it much. In fact, although it remains one of the principal reas
Q: I am looking for documentation or physician education tips related to ventilator manage
One of the new concepts in ICD-10-CM is the seventh character to denote the encounter type. In IC
APRIL 8, 2015
JUSTCODING
Q: A patient came to the ED with shortness of breath (SOB). The admitting diagnosis was possib
APRIL 22, 2015
JUSTCODING
NOVEMBER 20, 2013
JUSTCODING
We have a patient who is a 72-year-old man with a diagnosis of debilitating osteoarthriti
Coders are tasked with telling a patient’s story based on the documentation in the m
MAY 20, 2015
JUSTCODING
We all know that ICD-10 codes will require more complete documentation. We’ve been t
Q: If a physician documents sepsis due to decubitus ulcer and UTI due to indwelling catheter, c
The guidelines for principal diagnosis selection involving heart failure have changed over the ye
MARCH 26, 2014
JUSTCODING
  Why are physician queries so critical to accurate documentation and coding? The an
APRIL 2, 2014
JUSTCODING
Nurses new to home health struggle with the completion of documentation related to patient care.
MAY 13, 2015
JUSTCODING
Find out how one facility created an electronic health records (EHR) solution to improve m
MAY 20, 2015
JUSTCODING
The guidelines for principal diagnosis selection involving heart failure have changed over the pa
JANUARY 28, 2015
JUSTCODING
The guidelines for principal diagnosis selection involving heart failure have changed over the pa
MARCH 11, 2015
JUSTCODING
Q&A: Managing LS, EC, and EM documentation Editor
DECEMBER 20, 2016
We want physicians to be very clear in their documentation about what’s wrong with the pati
by Kirsten Dize Make completing documentation in the home a requirement for all
The Association of Clinical Documentation Improvement Specialists (ACDIS) honored the nation&rsqu
MAY 25, 2016
Q: Can you clarify the expectations related to documenting the discussion betwee
To assist healthcare facilities with the mandated adoption of ICD-10-CM diagnosis codes and ICD-1
JULY 12, 2012
FEBRUARY 25, 2015
JUSTCODING
By Stephen A. Berger, MD Even during “normal times,” summer
AUGUST 20, 2020
  When outpatient hospitals and physicians switch to ICD-10-CM diagnosis codes Oct
MAY 14, 2014
JUSTCODING
Q: We’ve heard that ICD-10-CM does not include a diagnosis code to show that a laparosco
DECEMBER 3, 2014
JUSTCODING
SEPTEMBER 23, 2015
JUSTCODING
We know we’re facing at least a one-year delay in ICD-10 implementation. What you with that
Coders aren’t the only ones who run into problems due to a lack of complete physicia
OCTOBER 29, 2014
JUSTCODING
  ICD-10 Compliance: Converting to a new diagnosis coding system
  ICD-10 Compliance: Converting to a new diagnosis coding system
  How SNF diagnosis coding differs from other healthcare settings
AUGUST 28, 2015
SEPTEMBER 24, 2014
JUSTCODING
by Megan Batty Capture a patient’s diagnosis of dementia due to Parkinson&
ACDIS, the Association of Clinical Documentation Improvement Specialists, the leading national as
FEBRUARY 8, 2011
DECEMBER 3, 2014
JUSTCODING
Q: My question is about the time interval requirement of the CPT® add-on
APRIL 2, 2014
JUSTCODING
Every provider has basic information he or she must document in the health record, says Lisa Ging
The proof of medical necessity strictly relies on the MD documentation and diagnosis and the skil
New EP: Avoid RFIs by keeping documents and service manuals in library “If it was
JANUARY 1, 2018
MARCH 18, 2015
JUSTCODING
Prioritization typically is one of the most difficult aspects for new nurses to learn. They know
New EP: Avoid RFIs by keeping documents and service manuals in library “If it was
DECEMBER 1, 2017
It’s hard to believe that the holiday season is upon us here again. One minute we’re
Although documentation matters more and more in today’s world of ever-changing regulations,
AUGUST 4, 2017
In recent years, hospitals have increasingly focused on creating clinical documentation improveme
The following changes to the Certified Clinical Documentation Specialist (CCDS) credential
As of April 1, coders now have a specific ICD-10-CM diagnosis code to capture the COVID-19 virus.
There has been a fair amount of coverage on the documentation requirements needed to assign ICD-1
The focus for clinical documentation improvement (CDI) specialists has historically been on the i
FEBRUARY 21, 2017
JANUARY 21, 2015
JUSTCODING
All patient medical record entries must be legible, complete, dated, timed, and authenticated in
APRIL 9, 2014
JUSTCODING
JUNE 18, 2014
JUSTCODING
What’s the number one financial reason for CDI initiatives? Improving the accuracy o
Principles of time management can help nurses—particularly new graduate nurses—accomp
NOVEMBER 30, 2017
To develop new strategies for improving physician and patient well-being and increasing the time
DECEMBER 15, 2017
Documentation: Getting the details right Joint Commission eli
DECEMBER 6, 2016
Documentation will be important to support supply utilization and payment. Claims
Documenting medical necessity has become a big topic over the last several years and there has be
MARCH 22, 2019
By Megan Batty Ensure that medical record documenta-tion clearly documents a canc
The Certified Clinical Documentation Specialist (CCDS) exam hit a pretty big milestone last weeke
MARCH 5, 2014
JUSTCODING
When you have an underperforming resident, this one resident can take up the majority of your tim
OCTOBER 17, 2014
A proposed CMS change to the 2017 Medicare Physician Fee Schedule will require surgeons document
SEPTEMBER 13, 2016
What documentation is necessary for a medication review? The regulation
Healthcare-associated infections have been getting attention for some time now, and you've likely
NOVEMBER 19, 2014
JUSTCODING
CMS posted updated versions of all the guidance documents posted on the
MARCH 26, 2014
JUSTCODING
It’s an age-old question: How do you get physicians to support documentation improvement ef
Coders face a daily struggle with selecting the appropriate principal diagnosis for patien
AUGUST 26, 2015
JUSTCODING
An Institute of Medicine report estimates that most people will experience at least one diagnosti
SEPTEMBER 23, 2015
Every have one of those days when you feel like you’ll never be warm? I’m having one
Never fear, ICD-10 will be here (hopefully) by this time next year. A week ago, the indus
To assist healthcare facilities with the mandated adoption of ICD-10-CM diagnosis codes and ICD-1
SEPTEMBER 29, 2011
Q: Our physicians document a diagnoses of pneumonia but do not normally make a specific
APRIL 9, 2014
JUSTCODING
Using a streamlined approach to EHR documentation may help reduce stress for resident, according
AUGUST 7, 2015
Editor’s note: This week’s Inside Story was adapted from one of HCPro’s bes
In addition to documentation by physicians, nurses’ documentation affects patient safety,
JANUARY 8, 2020
To assist healthcare facilities with the mandated adoption of ICD-10-CM diagnosis codes and ICD-1
JUNE 18, 2012
OCTOBER 22, 2014
JUSTCODING
Q: The primary physician documented subacute cerebral infarction and I am wondering whe
NOVEMBER 5, 2014
JUSTCODING
by: Kirsten Dize CMS’ revised OASIS Q&A document offers welcome insight
Be prepared to ask for time extensions from your accrediting organization and CMS to bring doors
OCTOBER 1, 2018
 Be prepared to ask for time extensions from your accrediting organization and CMS to bring
OCTOBER 1, 2018
One of the biggest stumbling blocks for ICD-10 implementation by small physician practices
Editor’s note: This week’s The Inside Story was adapted from one of HCPro&
Q: The primary physician documented subacute cerebral infarction and I am wondering whethe
Q: I have seen documentation of oliguric renal failure and non-oliguric renal failure. What is th
OCTOBER 21, 2015
JUSTCODING
Q: I have seen documentation of oliguric renal failure and non-oliguric renal failure. Wha
APRIL 23, 2014
JUSTCODING
Editor’s note: This week’s Inside Story was adapted from one of HCPro’s bes
The battle over timely reviews for Medicare claims denials continues despite a federal court&rsqu
Your relationship with the physicians you work with might be challenging from time to time. CDI s
New studies show overlapping surgery isn’t as risky (or as time saving) as once thought
MARCH 1, 2018
SEPTEMBER 30, 2015
JUSTCODING
There’s still time to register for our free 60-minute webcast, Effective Strategies for
OCTOBER 7, 2016
If you've served as a hospital safety official for any length of time, you know about the require
SEPTEMBER 10, 2015
One of our nurses asked us what her legal risks are if something goes wrong when caring f
One of the challenging aspects of coding arthroplasties is determining whether the procedu
AUGUST 20, 2014
JUSTCODING
Two items this week; one survey-related musing and a suggestion for your holiday season reading l
DECEMBER 6, 2018
This webcast is a companion program to the March cardiovascular diagnosis coding program,
FEBRUARY 11, 2015
JUSTCODING
JULY 15, 2015
JUSTCODING
Q: If a is patient admitted with malnutrition and the physician documented the patien
  A Comprehensive Error Rate Testing (CERT) study found insufficient documentation
JULY 22, 2015
JUSTCODING
Documentation Documentation
Q: We had a question regarding documentation in a record of SIRS due to acute peritonit
MAY 21, 2014
JUSTCODING
Time's running out. Is your CDI department prepared for ICD-10? Join Coding Boot Camp Instructor
In general, the time spent reviewing and coding records has increased since ICD-10 implementation
SEPTEMBER 10, 2014
JUSTCODING
Proper documentation is critical when it comes to supporting medical necessity and providing qual
Organizations often struggle to finalize charts after discharge so they can be coded in a timely
Q: Are records with only one MCC noted targeted by Recovery Auditors or other audit agenci
Providers don’t often receive education on clinical documentation, which can be a challenge
Healthcare is increasingly moving from a quantity-based system to a quality-based one. A quick gl
One of your many responsibilities as administrator is completing an annual agency evaluation, in
AUGUST 20, 2014
JUSTCODING
  Coders and clinical documentation improvement (CDI) specialists may not always a
JUNE 17, 2015
JUSTCODING
Infection control experts have been warning for some time now that the newest, and perhaps worst,
Infection control experts have been warning for some time now that the newest, and perhaps worst,
MARCH 1, 2018
If the patient qualifies for medical social services, the social worker can make one visit if th
The Association of Clinical Documentation Improvement Specialists (ACDIS) released a new position
NOVEMBER 5, 2014
MARCH 4, 2015
JUSTCODING
SEPTEMBER 23, 2015
JUSTCODING
One might think that accredited, major academic medical centers wouldn’t need to worry abou
Ensure accurate and efficient ICD-10, HCPCS Level II and CPT coding in one fell swoop with the
Documentation Two strategies for holding physicians accountable
By Steven Andrews   If healthcare workers lack one thing righ
Muscle weakness (generalized) was the most commonly used primary diagnosis that would be consider
FEBRUARY 12, 2014
JUSTCODING
Here are some of the highlights from the document/covid-recomm
AUGUST 27, 2020
  Medical staffs are discovering their governance documents are inadequate for tod
SEPTEMBER 18, 2014
Coding and documentation should tell a patient's complete story. With the greater specific
Editor’s note: This week’s The Inside Story was adapted from one of HCPro’s
I know some folks use the fiscal year (or as one boss a long time ago used to say, the physical y
NOVEMBER 29, 2018
The Outcome-Based Quality Improvement (OBQI) Manual is one in a series of four manuals pro
In the final days of 2015, CMS released a draft of OASIS-C2. The document includes some minor cha
One on One Education   On October 31, CMS released a c
Keeping staff safe is not only a moral obligation, but a legal one as well. SNFs need to ensure t
NOVEMBER 24, 2020
Think about the last time you took vacation. How many tasks, emails, and evaluations languished
MARCH 8, 2019
DECEMBER 23, 2014
JUSTCODING
Time’s almost up: CMS emergency prep CoPs kick in soon Th
OCTOBER 1, 2017
Editor’s note: This week’s The Inside Story is adapted from one of HCPro’s p
"[A]s we enter into clinical practice, physicians face the burdens of documentation and reg
SEPTEMBER 17, 2015
In the early days of clinical documentation improvement programs many staff members reported up t
The Joint Commission recently added one new and updated 19 existing online FAQs to clarify variou
It is no surprise that residents spend much of their time in clinical environments, making any ti
APRIL 5, 2019
  Documentation standards
JANUARY 1, 2015
In testament to one of the fastest growing segments of the healthcare profession, more than 500
FEBRUARY 21, 2011
Core privileges Is it time to revisit your hospital's au
Although writing meeting minutes is a tedious task, no one can dispute their importance. Besides
AUGUST 7, 2019
AUGUST 20, 2014
JUSTCODING
Editor’s note: This week’s The Inside Story was adapted from one of HCPro&
SEPTEMBER 24, 2014
JUSTCODING
Measure a wound from inside edge to inside edge to correctly document wound size, and ensure that
It's been said that you can't manage what you can't measure. Therefore, time managemen
Is it likely CMS will make any adjustments to the list of acceptable primary diagnosis co
A diabetes code was the most commonly coded primary diagnosis in both the wound and endocrine cli
One of the earlier episodes of the TV show The West Wing had the president of the United
FEBRUARY 1, 2018
ACDIS, the Association of Clinical Documentation Impro
APRIL 7, 2011
Doing it right the first time requires an investment of time, energy, and resources. But it&rsqu
No. The regulations do not mandate any particular form or format for documentation or confirmati
Noticing a lack of research into how residents spend off-duty time, medical researchers interview
JANUARY 8, 2016
One in three hospitals eligible for The Joint Commission's 'top performer' status has provided an
NOVEMBER 5, 2013
In the nearly six months I’ve been back in the consulting world, one trend during Joint Com
SEPTEMBER 11, 2014
The Advanced CDI Boot Camp is designed for established clinical documentation depar
  For the first time in some 20 years, CMS has updated its Conditions of Participati
FEBRUARY 1, 2017
Q: Is the statement “please document in a progress note to capture the severity of i
Editor’s note: This week’s Inside Story was adapted from one of HCPro’s bes
Moving on to the rest of the guidance document (it
FEBRUARY 21, 2019
Moving on to the rest of the guidance document (it still
FEBRUARY 28, 2019
Q: I am a coder in a hospital outpatient setting. Our physicians document drug use in s
JULY 22, 2015
JUSTCODING
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
JANUARY 19, 2016
OCTOBER 29, 2014
JUSTCODING
 It will depend a lot on documentation. This may be something to query. For example, even if
Friday, April 11 is the deadline to apply for the Certified Clinical Documentation Specia
  One interesting thing to note during a recent CMS validation survey up here in t
MAY 1, 2014
Is there ever a time we have to issue both an ABN and generic notice? Th
It’s storm season. Now’s the time to get your facility ready to face the power of Mo
MARCH 30, 2017
Patient rounds are an ideal time for clinical learning, but all too often faculty miss this oppor
DECEMBER 7, 2018
Although the rules for selecting QAPI data are flexible, CMS does require that programs document
There is one phenomenon in the PPS that has caught the attention of medical reviewers.
Communication is the establishment of a relationship where one person’s actions, thoughts,
JUNE 17, 2020
Proactive planning can save residents time and effort when applying for a medical license. The AM
JULY 17, 2015
Just in time for the holidays, CMS is offering the gift of a newly revised State Operations Manua
DECEMBER 23, 2019
G1024 (Authentication) is one of the more common standard-level deficiencies in 2018. G10
“Once upon a time, in a medical school far far away, I was taught that my sacred oat
DECEMBER 11, 2014
One of the benefits of doing a lot of traveling and having a fairly well-developed case of OCD is
JUNE 11, 2015
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
JANUARY 29, 2016
JULY 30, 2014
JUSTCODING
  Dear readers, There’s still time to register for our webcas
AUGUST 22, 2014
Focus on documentation. CMS believes it is the responsibility of the homecare provider to attempt
Providers have one last chance to volunteer for ICD-10 end-to-end testing, with CMS extend
MAY 13, 2015
JUSTCODING
The Joint Commission has updated its frequently asked questions and answers with one regarding t
APRIL 25, 2014
Unfortunately, one of the most commonly cited deficiencies in home health care is the failure to
Q&A Don't expect a one-size-fits-all reentry program
AUGUST 1, 2014
Nursing homes and personal care facilities are considered to have one of the
FEBRUARY 1, 2017
From time to time, hospice patients may travel outside of their current hospice provider’s
The Association of Clinical Documentation Improvement Specialists (ACDIS) last week updated its
OCTOBER 13, 2015
DECEMBER 3, 2014
JUSTCODING
AUGUST 6, 2014
JUSTCODING
Incidents reports are a pain to fill out, but vital for documenting what happened and for pro
SEPTEMBER 10, 2015
“I cannot count how many times I have had classmates confide in me that they were tired. An
JANUARY 27, 2017
Editor’s note: This week’s Inside Story was adapted from one of HCPro&rsq
Copyright statement
SEPTEMBER 4, 2008
One of the biggest scheduling struggles facing program directors is the service versus education
FEBRUARY 26, 2016
Editor’s note: This week’s The Inside Story was adapted from one of HCPro’s
  One thing for your to-do list (if it’s not already on your done list) is t
MARCH 27, 2014
In the interest of time and space (it's about time, it's about space, it's about two men in the s
MARCH 3, 2016