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

Charlie Coding Leave a Comment

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 …

MRA Thought of the Day–Don’t let technology “downtime” bring your staff down

Charlie Coding Leave a Comment

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 …

MRA Thought of the Day–Difficult Coding Scenario: Searching for an unlikely CC

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

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 …

MRA Thought of the Day–Countering the 1-10 Drop by Improving I-9 Tip #3

Charlie Coding Leave a Comment

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. …