The evidence for almost any diagnosis can be argued regarding the given variables within a record. This applies to both CDI professionals seeking to add diagnoses and auditors seeking to remove them.
The challenge for clinical documentation improvement specialists is in determining if the condition is an expected outcome of the procedure or patient’s disease process, or if it is an actual post-operative complication.
The minimum data set (MDS) coordinator is a key player in a skilled nursing facility’s (SNF’s) team.
Hospital billing is complex and accuracy is critical, as it can affect not only reimbursement, but hospital and physician quality scores as well.
As the current healthcare paradigm continues to shift to value-based care models with an outpatient emphasis, addressing outpatient clinical documentation is prudent.
Just as ICD-10-CM codes are used to translate clinical diagnoses into codified language, CPT codes identify diagnostic and therapeutic procedures and services using a systematic five-digit code.