A sixty-two year old patient is seen in the emergency room complaining of rectal bleeding. His HCT is 24 and his platelet count is 38,000. The admitting diagnosis is GI bleed. Makes sense. However, per the history and physical, the patient has a history of a bleeding arteriovenous malformation and myelodysplastic syndrome with recurring thrombocytopenia. During the admission of this …

Situation: In reviewing the medical record the coder notes disconnect between the physician documentation and the CDS documentation. Initial physician documentation indicates pneumonia with later documentation indicating acute bronchitis. The CDS worksheet indicates acute bronchitis. Was the pneumonia ruled out? Did the CDS obtain pertinent information about the patient’s diagnosis while attending physician rounds? Is there an outstanding query to …

Clinical coders are often sequestered within health information management (HIM) and incented to only code…not expand their horizons by keeping abreast of nationwide healthcare initiatives. But is this the best management approach? Situation: Several coders were breaking for lunch and an important conversation ensued. The coders began discussing future health care initiatives, challenges impacting the coding profession, and how difficult …

An elderly patient with a past medical history of CHF presents to the hospital with dyspnea and hyponatremia. Review of the history and physical indicates the patient’s daily Lasix dose was increased recently. What to do? Dig deeper! Upon further review, progress notes revealed that the patient has been non-compliant with a low sodium diet with excess water ingestion. The …

Recently, an inpatient coding validation audit was scheduled to be performed for a MRA client hospital. However clinical program passwords and system access had not been set up or tested. We simply could not get access to the medical record information we needed to conduct the work. Consequently, the review was delayed and productivity came to a grinding halt. The …

An 88 year old patient was admitted to the hospital after suffering a cerebral infarct. After review of the record, code 434.91 was assigned as the Principal Diagnosis along with several other chronic condition codes resulting in a DRG of 066 – Intracranial Hemorrhage or Cerebral Infarction without CC/MCC. No complication or comorbidity (CC/MCC) condition was identified. Or was a …

So the big question is, “How do I mitigate that drop in productivity?” You could hire an outsourcing company to provide coders through the transition. If you choose this option, go ahead and secure your contract now. Coding companies also expect an increase in work, and therefore demand, over the next two years. Their best resources are already getting assigned. …

So the big question is, “How do I mitigate that drop in productivity?” One answer is to hire more coders. However, you can’t find them now – never mind when the demand spikes for I-10. Here is tip #2 of five in our series to improve coder productivity and accuracy. You’ll see immediate results while also preparing for your long-term …

ICD-10 is around the corner and many sources are predicting an initial drop in coder productivity of up to 50 percent. This will be followed by an ongoing drop in productivity of 10-20 percent. In fact, a former HIM Director from Canada said her coders were never as productive in ICD-10 as they were in ICD-9. So the big question …