![]() The standard clinical documentation might even lead nowhere, like in the case of the common verbiage, “urosepsis.” If you have been met with incredulity, irritation, or outright outrage from a physician, you most likely have bumped up against a CCD. CDIPs who come from nursing have clinical experience, but it is not the exact same knowledge base as the physician or advanced practice provider.ĬCD is when the typical and customary documentation of a condition does not line up with the available codes or the indexing. The clinical documentation integrity professional (CDIP) practices at the intersection of the HCP and the coder. HCPs get precious little training about clinical documentation and know close to nothing about coding.Ĭoders know coding rules and the classification system, but any clinical knowledge they have comes from book learning or personal experience. The documentation gets translated into ICD-10-CM (International Classification of Diseases, 10 th Revision, Clinical Modification) diagnosis codes by coding professionals according to specific rules ( ICD-10-CM Official Guidelines for Coding and Reporting FY 2018). They practice clinical medicine and document to have a record of what transpired during the encounter for clinical communication. Healthcare providers (HCPs) are tasked with caring for patients. This week, I will address the higher-level problem of the “coding-clinical disconnect,” which I am going to refer to as CCD. Last week, I discussed the Type 2 MI issue. CCD is when the typical and customary documentation of a condition does not line up with the available codes or the indexing.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |