Health & Fitness:Medicine
On this episode, Dr. Tomas Villanueva and a leading clinical documentation expert finish their discussion on the need to correctly document everything involving spial surgery. Spinal surgery represents a complex challenge for documentation specialists and clinicians alike, and this episode will clear up what is needed to be successful in coding and documenting these procedures.
Moderator:
Tomas Villanueva, DO, MBA, FACPE, SFHM
Senior Principal
Clinical Operations and Quality
Vizient
Guest:
Rachel Mack, MSN, RN, CCDS, CDIP, CCS, CRC
Consulting Director
Clinical Documentation Improvement
Vizient
Show Notes:
[00:31] Query opportunities and low-hanging fruit
[01:53] Blood loss and the whole clinical picture in querying
[02:50] Using that “magic word” can make a difference – coding to an MCC
[03:43] Other query opportunities
[10:36] When the documentation is wrong
[12:44] Reconciliation and feedback needed
Links | Resources:
To contact Modern Practice: modernpracticepodcast@vizientinc.com
Rachel Mack’s email: rachel.mack@vizientinc.com
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