Use Queries to Prompt Complete Documentation
Queries (also know as clinical clarifications, documentation alerts, or documentation clarifications, among other names) are an essential component of any clinical documentation improvement (CDI)...
View ArticleCommunication Is Key to Code Lesion Excisions (and More)
Provider documentation does not always provide the information necessary to code with precision. For example, lesion excision codes 11400-11646 are size-based, with margins factored into the...
View ArticleAccurate Documentation is Essential – Knowing When to Query your Providers
by Pamela J. Haney, MS, RHIA, COC, CIC, CCS ICD-10 is finally a reality. We have learned to code diagnoses with ICD-10-CM, mastered the root operations in ICD-10-PCS, and we are ready to put our new...
View ArticleUse Queries to Prompt Complete Documentation
Queries (also know as clinical clarifications, documentation alerts, or documentation clarifications, among other names) are an essential component of any clinical documentation improvement (CDI)...
View ArticleCommunication Is Key to Code Lesion Excisions (and More)
Provider documentation does not always provide the information necessary to code with precision. For example, lesion excision codes 11400-11646 are size-based, with margins factored into the...
View ArticleAccurate Documentation is Essential – Knowing When to Query your Providers
by Pamela J. Haney, MS, RHIA, COC, CIC, CCS ICD-10 is finally a reality. We have learned to code diagnoses with ICD-10-CM, mastered the root operations in ICD-10-PCS, and we are ready to put our new...
View ArticleFrom Coder to Colleague through Querying
With a little encouragement, you can rise to challenges and become the “go-to” person. If you answer yes to any of these questions, you need some professional encouragement: Do you sometimes think you...
View ArticleClinical Parameters to Guide Provider Documentation Queries
When medical documentation is unclear or incomplete, the coder’s job is to query the provider. This can be done verbally or in writing, but not in an email or with a sticky note in the chart. With the...
View ArticleQuery Physicians to Improve Documentation and Dx Coding
Failing to thoroughly document signs and symptoms, assessments, and treatments of chronic diseases creates a ripple effect of misfortune. First, all relevant codes are not captured; this leads to...
View ArticleCommunicating in a Remote Working World
Working remotely or offsite has become the new normal for coders, making the art of communication more important than ever. But with such a large influx of young coders, it’s difficult for many who...
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