Topic: GI bleeding Scenario: 80 y/o female presents with coffee ground hematemesis with a PMH of GERD, CAD, and Iron deficiency Anemia. She has home medications of Protonix PO daily, SlowFe PO daily, and ASA 81mg PO daily. H&P notes: “acute upper GI bleed” with non-compliance with the Protonix and SlowFe because she says “they… Read More »Monthly CDI Scenario Discussion – December 2019
This training includes: Discussion of 2020 MS-DRG changes with CDI tip recommendations Discussion of 2020 IPPS changes with CDI tip recommendations Discussion of 2020 ICD-10-CM updates with CDI tip recommendations Why It’s Important: Coding is the basis of clinical documentation improvement Understanding coding fundamentals will assist in knowing what to look for in regards to… Read More »Code Updates and Tips for CDI
Are you ready to take your coding to the next level? What is single-path coding? It is a coding process where the coder codes both diagnoses and procedures for professional fee services and facility services at the same time using single-path coding (dual coding). It is performed by one coder who has the skill, knowledge,… Read More »Single-Path Coding Tip
For facilities performing CABG and other sternotomy procedures, readmission due to problems associated with sternal wires is just one type of complication that can occur post-operatively. The types of complications that can occur due to sternal wires include persistent pain, infection displacement, sternal dehiscence, and fractured wires. Most of these complications will require removal of the… Read More »Removal of Sternal Wires Following CABG
The annual updates to the ICD-10 and MS-DRG systems have been finalized, effective October 1. The ICD-10 and MS-DRG updates reflect the final Hospital Inpatient Prospective Payment System (IPPS) rule for the fiscal year 2020. You can see the details on IPPS here. Highlights of the MS-DRG changes include: Reassignment of 4 ICD-10-PCS codes for HCT procedures… Read More »UASI Training for FY2020 MS-DRG Updates
Topic: Fever of unknown origin Scenario: 65 year old male presented to the ED with a five-day history of increased congestion, cough, subjective fever, worsening lethargy, some confusion, weakness, and decreased oral intake. In the ED, the patient was febrile 102.0 F, heart rate 90, BP 112/71, RR18, SPO2 94% on room air. CT of… Read More »Monthly CDI Scenario Discussion – November 2019
Click here to download our article “Components of an Effective Inpatient Coding Compliance Program,” originally published in the January 2019 issue of the Journal of AHIMA.
CKD, Hypertension and Diabetes Mellitus: The Third Quarter 2019 Coding Clinic provided additional explanation and interpretation in regard to assuming a cause and affect effect relationship between CKD, hypertension and diabetes mellitus. Although previous advice regarding CKD, hypertension and diabetes provided in Fourth Quarter 2018 was not mentioned in the Third Quarter 2019 advice comparing… Read More »Coding Tip of the Month – October 2019
How to Get From Revenue Integrity to Revenue Intelligence For health systems and hospitals, claims denials have a significant impact on overall financial performance. From lost charges and Medicare/Medicaid cost outliers to defensive and forensic audits, the impact can reach into the tens of millions of dollars for large systems. The regulatory consequences can also… Read More »Six Rules for Successful Denials Management
Topic: Clinical Validation: Acute Post Operative Pulmonary Insufficiency/Acute Postoperative Respiratory Failure Scenario: H/P: 65 y/o male with past medical history of DMII, HLD, HTN, and obesity admitted with chest pain worse on exertion. Medications: Insulin, Metoprolol, Lisinopril, ASA, Crestor. BMI 34. Patient had a positive stress test. Cardiac cath shows severe three vessel disease and… Read More »UASI Monthly CDI Scenario Discussion – October 2019