World-class advice to address real-world challenges.
A recent discussion regarding lactic acidosis in a patient with sepsis has prompted a review of some important points that need clarification. First and foremost, lactic acidosis is not considered inherent to Sepsis. Additionally, acidosis is not noted as an...
In a recent Health Data Management article, Keystone Health Chief Operating Officer David Grant addressed the importance of ensuring clinician satisfaction with data integrity during EHR conversion. Legacy data missing from a new EHR can result in data gaps causing...
In October 2022, Intellis’ New Jersey-based client RWJBarnabas received an unprecedented perfect score from Epic for its EHR implementation project, as Becker’s Hospital Review reported. The Gold Star 10 ranking, the highest level of recognition a health system can...
Dementia: Will we need more queries? The short answer is yes! We need documentation of none, other, or a specified type of mood disorder. But here is the long answer: “Dementia The ICD-10-CM classifies dementia (categories F01, F02, and F03) on the basis of the...
When Lupus (unspecified) is documented in a record, there is no default code. Therefore, it is important to have providers document this condition as precisely as possible. For instance, document SLE (systemic lupus erythematosus) instead and add any complications...
Drug-induced neuropathy (D62.0) is a diagnosis often missed by even the savviest and seasoned coders. It is sometimes seen in documentation as ‘CIPN’ (chemotherapy-induced peripheral neuropathy) and is a common side effect caused by antineoplastic agents. Treatment...
Cachexia (R64) is also known as ‘wasting’ or ‘wasting syndrome’. It is a general state of weakness involving marked weight and muscle loss. Emaciated is another term that may be found in the documentation that also maps to code R64. These diagnoses are often missed...