The Importance of Proper HCC Coding

The Hierarchical Condition Category (HCC) risk adjustment scoring model is used by CMS and other payers to estimate the annual healthcare costs for beneficiaries, whether in Traditional Medicare or Medicare Advantage programs. The results directly impact the reimbursement to the health system. HCC scoring assigns a Risk Adjustment Factor (RAF) score to each diagnosis code […]


How a Clinical Documentation Improvement Nurse Can Help You

Medical record documentation must be complete and specific in order to: Promote better patient care and disease management. Accurately reflect the severity of illness (SOI) and risk of mortality (ROM) of the patient. These items have a critical impact on our published quality scores. Provide appropriate reimbursement for the care rendered. How Can a Clinical […]


Improving Documentation of Major Comorbid Conditions: Encephalopathy

As a follow up to Quality Update: Key Feature of Wave 3 Helps Providers Improve Documentation of Major Comorbid Conditions, let’s review encephalopathy. Encephalopathy is any diffuse disease of the brain that alters brain function or structure. It can be acute or chronic. Acute encephalopathy is reversible and resolves when the underlying cause is corrected. It […]


Correctly Coding Healthcare-Associated Pneumonia

As a follow up to Quality Update: Key Feature of Wave 3 Helps Providers Improve Documentation of Major Comorbid Conditions, let’s review healthcare-associated pneumonia (HCAP). HCAP requires specificity to be accurately coded. HCAP is considered to be one of the following types of pneumonia: Gram-Negative Pneumonia: E.Coli, Klebsiella, Proteus, Pseudomonas, Enterobacter and others Staphylococcal ( MRSA/MSSA) […]


Documentation of Respiratory Failure

As part of our ongoing efforts to educate providers about clinical documentation and its impact on patient safety and quality, our Clinical Documentation RNs have put together an overview of documenting respiratory failure. Documentation of respiratory failure requires the type and acuity level as noted below: Acute Hypoxemic Respiratory Failure Acute on Chronic Hypoxemic Respiratory […]


Documentation of Malnutrition

As a follow up to Quality Update: Key Feature of Wave 3 Helps Providers Improve Documentation of Major Comorbid Conditions, let’s look at documentation of malnutrition: Malnutrition should be specified by degree: Mild, Moderate or Severe. There are several criteria that our registered dietitians review when determining the degree of malnutrition. These criteria follow guidelines […]


Correctly Coding Congestive Heart Failure

As a follow up to Quality Update: Key Feature of Wave 3 Helps Providers Improve Documentation of Major Comorbid Conditions, let’s review congestive heart failure (CHF). In order for CHF to be correctly coded from the medical record, the following needs to be addressed in your progress notes: Type: Diastolic, Systolic or combined Diastolic and […]


Quality Update: Key Feature of Wave 3 Helps Providers Improve Documentation of Major Comorbid Conditions

Accurate documentation of major comorbid conditions (MCC) is critical for patient care and hospital reimbursement. It also directly impacts our publicly reported quality scores and value-based purchasing. In Wave 3 of the Epic Refuel, the Admission Navigator will have a new “Co-morbidities” section that suggests patient-specific diagnoses based on real-time vitals, labs, and other data […]


New CPT Code for Anticoagulation Management

In 2018, a new CPT code was added for anticoagulation management. The code is 93793. This code has an active status in the Medicare Fee schedule with an RVU value of 0.18. 93793 anticoagulation management for patients taking warfarin must include review and interpretation of a new home, office, or lab international normalized ratio (INR) test results, […]


Clinical Documentation Improvement (CDI) Query: Why is it important? How can I respond?

CDI Queries are sent to providers from our nurse inpatient coding specialists requesting additional information on patient charts.  Accurate, complete, and timely documentation in the medical record impacts the calculation of the patient’s Severity and Illness (SOI) and Risk of Mortality (ROM).  This documentation of SOI and ROM consequently has a critical impact on our […]