Q: I’ve heard conflicting information about reporting uncertain diagnoses. Do the ICD-10-CM diagnoses need to be documented in the discharge summary/final progress note or can they be coded from an earlier progress note?
Q: If a patient is requesting his medical records via email, so long as our email is encrypted and secure, can we send it? We only have his email on his admission papers, which matches the email address he sent to us.
This week's note from the instructor walks through the background of and processes involved in creating a Medicare Coverage Analysis document prior to billing for a clinical trial.
One of the most vexing challenges that CDI specialists have is how to engage physicians to completely and precisely document their patients’ conditions and treatments in the language required by ICD-10-CM, which is essential to risk adjustment.
More than half of those who are homeless or considered “marginally housed” have had a traumatic brain injury (TBI) at some point in their lives, and a quarter of them experienced a brain injury that was considered moderate or severe, according to a study published online by The Lancet in December.
