Posts by Staff
Complication of a Device CDI Scenario – January 2022
The CDI Scenario for January 2022 covers complication of a device, specifically with a Foley catheter causing UTIs.
Read MorevNotes Hysterectomy – December 2021 Coding Tip
December 2021’s coding tip covers how to code a vNotes hysterectomy, a procedure done under endoscopic vision.
Read MoreHemiplegia Secondary to Stroke Outpatient CDI Scenario – December 2021
December’s CDI Scenario covers hemiplegia secondary to stroke. A 78 year old diabetic male with a history of falling goes to the doctor.
Read MoreNeurogenic Shock and Spinal Shock CDI Scenario – November 2021
November’s CDI Scenario covers neurogenic shock and spinal shock. A 58 year old male enters the ER after hitting his head.
Read MoreTop 10 Documentation and Coding Issues for Physician Practices in 2021
Make sure you are addressing these top documentation and coding compliance concerns. Risk-based review of evaluation and management codes (E/M): Appropriate application of FY21 E/M code guideline changes Telehealth visits (audio and visual vs. telephone only); Medicaid behavioral health telehealth Review providers with higher than 10% of visits in level 4 and 5, or outliers…
Read MoreTop 10 Documentation and Coding Issues for Hospitals in 2021
Make sure you are addressing these top documentation and coding compliance concerns. Risk-based review of inpatient DRG cases, examples include: RAC DRG targets; PEPPER targeted DRGs COVID related inpatient discharges Clinical indicators, cases at risk for clinical denials (e.g. Sepsis, CHF, ARF, severe malnutrition, encephalopathy) IP cases with only 1 MCC/CC code or HAC/PSI cases…
Read MoreShock CDI Scenario – August 2021
H&P: 58 yr old male with chest pain and SOB presents to the ER. Troponins ordered along with EKG revealing nonspecific ST changes with rising levels. Cardiology consult for NSTEMI with orders for ASA 325mg x1, Nitropaste, and o2. While waiting on consult, patient became lethargic and pale with fingertip cyanosis noted. Repeated VS showed:…
Read MoreFHIMA 2021 Recap
The 2021 Florida Health Information Management Association (FHIMA) Annual Convention took place July 19-21 in Orlando. UASI sent Regional Market Manager Brad Allen, Vice President of Strategic Initiatives Michael Burke, and Vice President of Corporate Development Nancy Koors to the Sunshine State in order to catch up with Florida HIM professionals. Although the Convention was…
Read MoreFY 2022 ICD-10-CM Updates
Abnormal Findings on Neonatal Screening Currently there is only a single code to capture any or all types of newborn screenings that may have positive or abnormal results. The American Academy of Pediatrics requested expansion of category P09 Abnormal findings on neonatal screening, to specifically show which screening categories were abnormal. Table 1 shows the…
Read MoreThe Role of a Physician Advisor
Given the heightened focus on documentation and impacts to healthcare organizations from both a financial and quality perspective, it is imperative that clinical documentation improvement (CDI) leaders implement an effective strategy to develop a physician advisor program. The success of a CDI physician advisor program hinges upon defining the physician advisor’s role. A physician advisor…
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