MRA Thought of the Day—Discharge Summaries Seal the Deal

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Coding a medical record with incomplete documentation jeopardizes coding accuracy and negatively impacts reimbursement. However, sometimes real world situations prohibit Coding Managers from adhering to best practice standards. In the following scenario the discharge summary provided clarifying documentation; leading to the right diagnosis and reimbursement. A patient with a past medical history of lacunar infarct with residuals presents with facial …

MRA Thought of the Day-Back to the Basics: Coding Conventions

Cathie Wilde, RHIA, CCS, AHIMA Approved ICD-10-CM/PCS Trainer Coding Leave a Comment

A forty-six year old patient arrives in the emergency room with chief complaint of confusion as described by patient’s spouse. A thorough work up is undertaken including blood work, radiological testing and a neurology consult. No etiology for the confusion is identified. The attending physician documents the final diagnosis as “acute confusional state, cause unknown”. Using the encoder, the coder …

MRA Thought of the Day -Clinical Documentation Validation and Coding Compliance

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Situation: Clinical Documentation Improvement Managers (CDIMs) continually monitor the success of their healthcare organization’s CDI program. The metrics they use commonly include volume of queries issued, query success, case mix data, severity of illness, and risk of mortality data. However, there is another critical element that should be monitored by the CDIM: clinical documentation validation.Clinical documentation validation risk assessments should …

MRA Thought of the Day: Secondary Diagnoses Matter! Check Your Grouper

Cathie Wilde, RHIA, CCS, AHIMA Approved ICD-10-CM/PCS Trainer Coding Leave a Comment

It is important that your coding staff identify and code all pertinent secondary diagnoses that meet additional diagnoses criteria (as outlined by Coding Clinic, 4Q 2008, p. 305-306). In this month’s case, the identification of another secondary diagnosis meant an extra $22,000 in hospital revenue.More than Just Another Code Coders should never presume that a valid secondary code makes no …

MRA Thought of the Day – Finding Support for Medical Necessity in Outpatient Services

Cathie Wilde, RHIA, CCS, AHIMA Approved ICD-10-CM/PCS Trainer Coding Leave a Comment

Do the diagnosis codes that you submit on your claims support medical necessity? When you are coding patient encounters, do you assign diagnosis code(s) based only the final diagnosis documented by the provider, or do you review the record for chronic conditions that are being followed and should also be coded? CMS, and other local insurance carriers, have medical coverage …

MRA Thought of the Day – Clinical Documentation Specialists Provide Insight: Partner Up for Coding Accuracy

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Strong communication between clinical documentation specialists (CDS) and clinical coders is vital to the success of any clinical documentation improvement program. But additional benefits may be gained through ongoing exchange between these two teams. Here’s a real-world example. Situation: In reviewing the medical record, the coder notes disconnect between the physician documentation and the CDS documentation. The initial physician documentation …

MRA Thought of the Day-Grasping the Full Definition of Principal Diagnosis

Cathie Wilde, RHIA, CCS, AHIMA Approved ICD-10-CM/PCS Trainer Coding Leave a Comment

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 …

MRA Thought of the Day-CDS Documentation Provides Insight to Ruled Out Diagnosis

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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 …

MRA Thought of the Day-Expanding Coding Horizons: Three Healthcare Initiatives to Watch

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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 …

MRA Thought of the Day–Clinical Documentation versus Clinical Evidence

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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 …