Documentation TipSearch JobsClient Portal

Documentation Tip

BI-RADS (Breast Imaging-Reporting and Data Systems)

Download this tip
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors

Clinical Documentation Integrity Tips

2022 Documentation Updates
Acidosis
Acute and Chronic Cor Pulmonale
Acute Encephalopathy
Acute Myocardial Infarction: Documentation to Support Quality
Acute Renal Failure (ARF) / Acute Kidney Injury (AKI)
Acute Respiratory Distress Syndrome
Acute Respiratory Failure
Acute Tubular Necrosis (ATN)
Age-Related Debility
Anemia
April 2022 Documentation Updates
Aspiration Pneumonia
Asthma
Atrial Fibrillation: 2020 ICD-10 Code Updates
BI-RADS (Breast Imaging-Reporting and Data Systems)
Brain Compression and Cerebral Edema
Brain Injuries
Cachexia
Catheter-Associated Urinary Tract Infection (CAUTI)
Chest Pain Level of Care
Chronic Kidney Disease
Chronic Respiratory Failure
Cirrhosis
Clinical Documentation Integrity Golden Rules
Clinical Language and Coding Rules
Closed Reduction of Fractures and Splint for Trauma
CMS Quality Reporting – COVID-19 Update
CMS Star Rating
CMS Three Day Rule
Coma
Common Angioembolization and Ultrasound Procedures for Trauma
Common ED Procedures for Trauma
Common Operative Procedures for Trauma
Condition Code 44
Conflicting Documentation
COPD
COPD Exacerbation: Documenting Medical Necessity
COVID-19 Documentation and Coding Tips: 2021 Update
CT and MRI Procedure Codes for Trauma
Decubitus Ulcers
Deep Tissue Injury
Demand Ischemia
Demand Ischemia Update
Dementia
Depression
Depressive Disorder
Diabetes
Diabetic Coma
Discharge Summaries
Discharge Summary Importance
Documentation Issues Facing Supervising Resident Physicians
Documentation Using a Diagnosis-Specific Approach
Drug Toxicity And Poisoning
Encephalopathy
Encephalopathy using GCS
Encephalopathy, Unspecified
End of Life Care
End-of-Life Care
ESRD After Kidney Transplantation
Evaluation and Management Coding for Observation Status
Excisional Debridement
Excisional Debridement for Trauma
Fourth Universal Definition of Myocardial Infarction
Fractures
Fractures of Face, Upper Body and Upper Extremities for Trauma
Fractures of Hand, Pelvis, Femur and Patella for Trauma
Functional Quadriplegia
FY 2024 Common Cardiac MCCs AND CCs
GI Bleed
Glasgow Coma Scale / Pediatric Trauma Score
Global Malnutrition Composite Score
Guidelines for Home Oxygen for Medicare Patients
HAC Reduction Program
Healthcare-Associated Pneumonia (HCAP)
Heart Failure
Heart Failure – Universal Definition
Heart Failure: Framingham Criteria
Hepatic Encephalopathy Update
Hepatorenal Syndrome
History Of
HIV
Homelessness
Hospital Acquired Conditions (HAC)
Hypercoagulable State
Hypertension
ICD-10 Surgical Root Operation Definitions
Influenza
Intracranial Abnormality
Ischemic Hepatitis
Le Fort Fracture
Length of Stay (LOS) Impact
Linking for CDI and Coding
Linking for the Physician
Malnutrition
Malnutrition: Increased Scrutiny
Malnutrition: Reducing Readmissions
Medical Necessity Documentation I
Medical Necessity Documentation II
Mortality Metric Optimization
Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA)
Myocardial Injury
National Guideline For The Field Triage of Injured Patients
Nelson Score for Trauma
Nicotine Dependence & Withdrawal
Obesity Documentation
Occurrence Span Code 72
Outpatient HCCs
Oxygen Equivalency Table
Pancreatitis
Patient Safety Indicator (PSI) 04
Patient Safety Indicator (PSI) 10
Patient Safety Indicator (PSI) 15
Patient Safety Indicator (PSI) 9
Pediatric Respiratory Failure
Physician Queries
Pneumonia
Pneumonia Specificity
Poorly Controlled Seizure Disorder
Postoperative Conditions
Postoperative Respiratory Failure
Present on Admission (POA)
Principal Diagnosis
qSOFA and Sepsis-3
Race 1 and Spanish/Hispanic Origin Codes
Radiology, Pathology and Lab Results
Recovery Auditor Protection II
Recovery Auditor Protection II
Rhabdomyolysis
Risk Adjustment
Secondary Diagnoses
Secondary Diagnosis #1-10 Codes (DX>2018)
Sepsis as an Indication for Surgery
Sepsis-2 to Sepsis-3 Crosswalk
Sepsis-2: More than the SIRS Criteria
Sepsis-3
Sepsis-3 Denials
Sepsis-3 SOFA Made Easy
Severe Sepsis
Severe Sepsis and Septic Shock Management Bundle
Shock
Shock Index (SI) for Trauma
Shock v. Septic Shock
Social Determinants of Health
Stroke
Stroke for ICD-10
Substance Use/Abuse/Dependence
Surgical Complications
The Importance of Documentation Continuity
The Verboten List
Thiamine Deficiency
TKA Second Midnight Questionnaire
TKA/THA Medical Necessity
To Cover
Top 10 ICD-10 Documentation Tips
Traumatic Brain Injury
Traumatic Rhabdomyolysis
Troponemia
Type 2 MI
Type 2 MI – Risk of Mortality