CDI Team: Excisional versus non-excisional debridement

The CDI team has noticed an increase in the number of queries being sent to physicians regarding excisional and non-excisional debridement. Coders cannot assume that the debridement of bone, fascia or muscle is always excisional.

How to ensure the discharge summary is complete

This month, I would like to focus on the Discharge Summary. Perhaps one of the most important elements of documentation, the Discharge Summary serves as a communication tool for primary care providers, summarizes the hospital course for future reference and is a primary source of information for coding and billing. Despite its multiple uses, discharge summaries often lack the core elements that allow them to serve such functions.

Improving clinical documentation: ICD-10 tips on influenza

From the time we began planning for the implementation of ICD-10, we maintained the position that our mission is to help providers become better documenters, not coders.