Clinical Documentation Integrity – Success in Written Policies and Procedures

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer AHIMA Leave a Comment

While writing policies and procedures often seem to be time-consuming and a challenge, they have many positive benefits that cannot be overlooked. For Clinical Documentation Integrity (CDI) program having written policies and procedure is part of compliance and the day-to-day operations of the CDI staff. When we think about written policies and procedures (P&Ps) we often...

Planning and Preparing for Coding Updates . . . Key Steps

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer Medical Coding Leave a Comment

The Centers for Medicare and Medicaid Services (CMS) released their proposed Fiscal Year 2023 ICD-10-CM coding update and the final ICD-10-PCS codes changes. The ICD-10-CM proposal has some significant changes and new codes. The ICD-10-CM does have a high volume of new code to absorb and learn about. The ICD-10-PCS is always of interest with new procedure and devices...

A Pox On You? Hopefully Not!

Becky Buegel, RHIA, CDIP, CHP Medical Coding Leave a Comment

Recent media reports document an increase in suspected and confirmed cases of the monkeypox virus. Monkeypox, first detected in lab monkeys in 1958, may have earned its moniker from the lab monkeys, but it’s actually thought it originally spread to humans from wild animals like rodents; today’s thinking is that it’s either spread by wild animals or from contact with other...

CPT Updates for 2022: Spinal Fusions

Caitlin Wham, CCS CPT updates Leave a Comment

Each year the AMA (American Medical Association) publishes new, revised, and deleted codes to the CTP code set, including logic and rationale related to the updates. The CPT code set for 2022 includes several changes regarding spinal fusions- including revisions of guidelines, parenthetical notes, definitions and coding instructions. The key changes regarding spinal...

CERT Overpayment Report - Documentation is the Key

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS HHS 1 Comment

The 2021 Comprehensive Error Rate Testing (CERT) report contains statistics on improper payment made by the Medicare program to providers and is published annually. The CERT data is supported by a sample of Medicare Fee-For-Service (FFS) claims that were reviewed by an independent medical review contractor to determine if they were paid properly under Medicare coverage,...

ICD-10-CM Underdosing Guidelines and Accuracy

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS Medical Coding Leave a Comment

The clinical coding of “Underdosing” has some very specific guidelines which must be understood and followed. We see “underdosing” scenario’s occur in both outpatient and inpatient encounters. Several ICD-10-CM codes will need to be assigned in order to capture the underdosing patient encounter accurately.  The clinical coding of a condition or diagnosis of “Underdosing”...

What Is Anemia? A Simple Question With Some Not So Simple Answers

Becky Buegel, RHIA, CDIP, CHP Medical Coding Leave a Comment

The question is simple – What is anemia? However, the answer is not necessarily so simple. Anemia is a condition that is marked by a deficiency of red blood cells, or hemoglobin. Anemia can be linked to a variety of conditions and diseases, and can affect people of all ages, races, and ethnicities. The more common forms of anemia are noted below.  NUTRITIONAL-DEFICIENCY...

Query Compliance...Time to Confirm This!

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS CMS Leave a Comment

Within Clinical Documentation Integrity (CDI) and clinical Coding we have verbal, written and electronic documentation clarifications or querying. A key component of the clinical documentation query is achieving and maintaining compliance. Having a written policy and procedure in place along with a formal quality review process for querying is thus essential and a must. ...

HHS Releases Strategic Plan FY 2022–2026

Heather Chartier, MS, RHIA, CCA HHS Leave a Comment

In March 2022, the U.S. Department of Health and Human Services released the updates for its Strategic Plan. All operating and staff divisions within the HHS and input from Congress, Tribes, Tribal, and Urban Indian Organizations, the Office of Management and Budget, and the public sector contributed to its development. For FY 2022 – 2026, HHS addresses and tracks five...

CPT Updates for 2022: Musculoskeletal System Section

Caitlin Wham, CCS CPT updates 1 Comment

Each year the AMA (American Medical Association) publishes new, revised, and deleted codes to the CPT code set, including logic and rationale related to the updates. The CPT code set for 2022 includes extensive changes to the Musculoskeletal System section, which had a large number of updates in both guidelines and definitions. The key changes to the Musculoskeletal...

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