Principal Diagnosis Selection: Essential Guidelines for Capturing Appropriate Documentation and Coding - On-Demand
Presented: Monday, July 13, 2015
Originally presented on Thursday, May 15, 2014
It isn't easy picking the principal diagnosis from a medical record filled with signs, symptoms, and secondary diagnoses, but doing so effectively can make the difference to your facility's publicly reported quality scores - and, perhaps more importantly, to its bottom line.
If your CDI and coding team struggle to understand the Official Guidelines for Coding and Reporting and need help parsing the various nuances of the requirements, we can help.
At the end of the program, participants will be able to:
- Select the principal diagnosis based on the UHDDS definitions and coding guidelines
- Describe CDI and coder role in relationship to coding and query compliance, ethical coding
- Identify coding guidelines governing contrasting and comparative diagnosis and symptoms principal diagnosis selection
- Describe how combination and etiology/manifestation codes influence principal and secondary diagnosis selection.
- Identify chart review/query strategies related to common related to the capture of principal and secondary diagnoses
- Describe how the principal and secondary diagnosis choice can affect quality measures and possible medical necessity denial
- Guidelines for principal and secondary diagnosis selection
- Official Guidelines for Coding and Reporting
- Coding Clinic
- ICD-10-CM guideline implications
- Includes/excludes notes
- Code first, code also
- Combination codes
- ICD-10-CM clinical documentation needs and query opportunities
- Sequencing for anemia
- Respiratory failure
- Principal diagnosis selection and MS-DRG assignment
- CC/MCC capture
- Relative weight
- Length of stay implications
- Influence upon quality measures, medical necessity denials
- Coding and documentation
- Principal diagnosis of symptoms following comparative/contrasting diagnosis
- Principal diagnosis coding of comparative/contrasting diagnoses (with no symptoms)
Who Should Listen
CDIs, Coders, Quality, Finance
AHIMA - This live program has been approved for 1 continuing education unit for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor
CCDS: This live program has been approved for 1.5 continuing education units towards fulfilling the requirements of the Certified Clinical Documentation Specialist (CCDS) certification, offered as a service of the Association of Clinical Documentation Improvement Specialists (ACDIS).
Meet the Speakers
Laurie Prescott, MSN, RN, CCDS, CDIP, is a CDI education specialist for HCPro in Danvers, Mass. In 2007, Prescott implemented a clinical documentation program at a community hospital in North Carolina. She spent the majority of her nursing career in acute care, primarily medical surgical, with experience in ICU, PACU, endoscopy, and one-day surgery. She has worked as unit manager of med-surg and ICU units, served as an adjunct professor for an ADN program, and later stepped into the role of director of education and clinical support of nursing staff. In addition, she has experience with both regulatory and compliance issues.
Lynda Starbuck, RHIA, C-CDI, AHIMA Approved ICD 10 CM/PCS Trainer
Manager, Coding and Documentation
Quorum Health Resources, LLC
Lynda is a Coding and Documentation Manager at Quorum Healthcare Resources, LLC. Prior to Quorum she was the managing consultant for Navigant healthcare and has more than 25 years' experience in clinical documentation integrity, coding, health information management, professional and facility-based evaluation and management, and business office management, and education for clinical and nonclinical staff, including physicians. She has provided CDI and medical necessity education to students in healthcare majors, clinical and nonclinical staff, and hospital ancillary staff.
Webinar system requirements and program materials:
To fully benefit from the webinar experience, please note you will need a computer equipped with the following:
Internet: 56K or faster Internet connection (high-speed connection recommended)
Streaming: for audio/video streaming, Adobe Flash plug-in or Safari browser on iOS devices
Prior to the webinar, you will receive an email with detailed system requirements, your login information, presentation slides, and other materials that you can print and distribute to all attendees at your location.
COULDN'T LISTEN LIVE?
No problem. The On-Demand version is also available. Use it as a training tool at your convenience—whenever your new or existing staff need a refresher or need to understand a new concept. Play it once or dozens of times. A $199 value!
Participation in this webinar is just $199 per site. All materials must be retrieved from the Internet.
Call your customer service representative toll-free 800-650-6787 or email email@example.com if you have questions.