Pay close attention to new CPT documentation and coding guidance for reporting radiological imaging. For example, a new paragraph titled “Imaging Guidance” in both the surgery and medicine guidelines advises that even when imaging guidance or supervision are included in a surgical procedure code, you must still follow the radiology documentation requirements in the CPT manual.
Experts Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS review the recently published “Global Leadership Initiative on Malnutrition (GLIM) Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community” and help coders apply this criteria in ICD-10-CM.
Establishing an outpatient CDI program can have substantial benefits. Recently, an outpatient CDI review project demonstrated there were many documentation improvement opportunities at a large family practice/internal medicine physician clinic.