By Justin Bariso, Principal, EQ Applied Reprinted with Permission “You know, you’re the type of manager the rest of us hate.” I’ve never forgotten when someone told me that. I was only 23, and I was working in a factory in downtown Brooklyn. We were making encyclopedias (remember those?), and our job was to quality […]

By Justin Bariso, Principal, EQ Applied Reprinted with Permission Thomas Keller is an award winning chef and restaurateur. Over the years, he’s developed a reputation as one of the most skilled culinary artists in the world. But in 2015 Pete Wells, the lead restaurant critic for the New York Times, made headlines when he published […]

by Laura Gerovac, PT and HIT Student I am truly thrilled that on my career journey, both my physical therapy experience and medical coding/health information pathways have converged into that of a Trauma Registrar. This has been a perfect match for me, being able to combine and connect both fields. A Trauma Registrar is indeed […]

By Victoria Jennings, RHIA, CCS, CPC-A Here is what you specifically need to understand about education: “When an atmosphere encourages learning, learning is inevitable.” (Elizabeth Foss) Well, that sounds very reasonable. But what makes an “atmosphere that encourages learning?” Thinking now of my providers, what will increase their willingness to learn? I have been educating […]

By Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA For both the 9th and 10th versions of the WHO’s International Classification of Diseases, the US clinically modified ICD, significantly expanding the code set to address classification needs in the US. The ICD-10-CM code set, though based on and compatible with the WHO’s ICD-10, includes thousands […]

By Kay Piper, RHIA, CDIP, CCS Merriam-Webster Dictionary definitions of “uncertain” shed light on why a provider may use an uncertain term. Scan this list of definitions… Dubious – giving rise to uncertainty, doubtful outcome, questionable or suspect as to true nature or quality Doubtful – unsettled opinion, marked by qualities that raise doubts about […]

By Jen Flohr, RHIT, CCS, CDIP, CPCO, CAMP, COC, CPMA A Universal Patient Identifier (UPI) is a single medical identification number, much like a Social Security number, that is unique to each person and used to distinguish their medical information from anyone else’s. In a recent AHIMA survey, a majority said that policies aimed at […]

By Justin Bariso, Principal, EQ Applied Reprinted with Permission I almost killed the perfect vacation. A couple of years ago, I was enjoying a wonderful trip with my family to the Italian coast. It was perfect: 10 days of good food, great sun, and beautiful beaches. Then, I caught a bad cold. I considered staying […]

By Kay Piper, RHIA, CDIP, CCS This is the third of a 3-part series on my research on terms that organizations accept as reasonable phrases for uncertain diagnoses in absence of official advice from either Coding Clinic or Official Guidelines for Coding. In Part 1 of this series we reviewed what we know for sure–the […]

If your career goal is to work as a hospital coder you probably hear a lot about coding credentials. And you may be thinking, “What’s the big deal? Are they really that important?  Are they really worth the time and energy to pursue?” First, let’s note what a credential is: it is an authentication (or […]

By Kay Piper, RHIA, CDIP, CCS In the absence of official advice from either AHA Coding Clinic or Official Guidelines for Coding and Reporting, I am researching which terms organizations accept as reasonable phrases to document uncertain diagnoses. In Part 1 of this series we reviewed what we know for sure–the Inpatient and Outpatient ICD-10-CM […]

By Justin Bariso, Principal, EQ Applied Reprinted with Permission Years ago, I was watching an interview with comedian Craig Ferguson, when he gave some very sage advice: There are three things you must always ask yourself before you say anything. Does this need to be said? Does this need to be said by me? Does […]

by Kay Piper, RHIA, CDIP, CCS As an Inpatient Coder or Clinical Documentation Specialist (CDS), do you, like me, feel relief that ICD-10-CM Guidelines direct to code an uncertain diagnosis documented at discharge as confirmed? You can probably recite the uncertain terms listed in Guideline II.H Selection of Principal Diagnosis and Guideline III.C Reporting Additional […]

By Victoria Jennings, RHIA, CCS, CPC-A CPT coding of office visits changed significantly in 2021. Now is a good time to conduct a review of your documentation for office visit codes to ensure current compliance and start preparing for whatever changes are slated for 2022. Your clinical staff involved with documentation in the record (Doctors, […]

By Victoria Jennings, RHIA, CCS, CPC-A Getting providers to pay attention and perhaps make changes in how they document or code their services can be challenging. As a coding educator, I find a combination of different techniques is sometimes necessary. My husband is a manufacturer’s representative and has been in sales all his life. He […]

by Cheryl A. Cyrus, BGS, AS, RHIT, CPMA, CDEO, CRC Life is always moving forward and changes are always happening. Many things you learn may not seem like education at the time but they make you who you are and prepare you for your next challenge. I started working during the summer between my junior […]

By June Bronnert, MHI, RHIA, CCS, CCS-P You may be asking: ICD-11. Why now? My answer: Why not now? The pandemic has shown the power of integrated data capture and collaboration across terminologies and code sets allowing for sharing of information and innovation. ICD-11 leverages the strengths of different systems to create a modernized classification […]

by Clay Lee, Associate, Epstein Becker Green Medical providers are often asked, or feel obligated, to disclose confidential information about patients. This blog post discusses when disclosures of confidential medical information involve law enforcement, but the general principles discussed herein are instructive in any scenario. To protect patient confidentiality and avoid costly civil liability arising […]