How to code gastrointestinal conditions with or without bleeding has been a topic of discussion among coding professionals and clinical documentation improvement (CDI) professionals since the publication of the third quarter 2017 issue of the American Hospital Association’s Coding Clinic. Coding Clinic advised coders to apply the “With” guideline associating bleeding to the gastrointestinal condition even when the medical record lacks a causal relationship documented by the physician.
After years of screening mammograms, always with results that came back clear, Nancy M. Cappello, PhD, was shocked to receive a diagnosis of advanced stage 3 breast cancer. The reason the mammography hadn’t found anything sooner, she learned, was because she had dense breast tissue—a term she had never heard until her cancer diagnosis. This post discusses some basics for mammography coding as it may have related to Nancy Cappello’s experience.
What if there were streamlined claims submissions, remittance, and payments for the provider with real-time determinations and claims adjudication for the payers?
As the coding profession has evolved tremendously, so too have the needs of coding professionals. Experienced coders need education and training tools that will elevate their skill set to match the needs of employers. Today, coders need to be clinically savvy to make intelligent decisions about the documentation.
Computer-assisted coding (CAC) has become a commonly recognized presence on the health information management scene, so much so that we now have coders in the workforce that have likely only ever briefly trained on coding without CAC—or potentially have never worked without CAC at all.
It feels like it has been much longer since the days when many coding professionals were working in the basement of a hospital, still coding from paper charts, the idea of being able to work from home much more dream than reality—but the telecommuting coder has been a relatively recent phenomenon.