Critical care coding can challenge both new and seasoned coders. Jessica Miller-Dobbs, CPC, CPC-P, CGIC, offers tips and clarification on reporting critical care services in CPT, as well as sample provider documentation for these services.
After identifying areas of concern related to missing or inaccurate information on discharge paperwork, CMS is encouraging surveyors to keep an eye out for documentation gaffes.
Medical necessity is a term used to describe the need and justification for services a patient will receive, including diagnostic studies or therapeutic treatment. Understand how Medicare defines the term and what requirements must be met.
The CDI educator role is dynamic, evolving to fit the ever-changing landscape of coding and CDI. Consider these tips to help ensure your CDI educators are meeting current needs.
As case managers review the medical record and interview the patient, family, and medical team, they must dig deep and ask hard questions to ensure any unforeseen financial or medical needs are met.
Terry Tropin, MSHAI, RHIA, CCS-P, reviews the biggest changes to the 2024 ICD-10-CM guidelines and tabular list set to take effect October 1, including deletions of certain COVID-19 screening guidelines, and additional direction for new resistant hypertension and myocardial infarction codes.
