Many outpatient CDI professionals stepped into their roles blind—not knowing where to begin or how to tell if they were successful. However, as programs mature, they need to be able to track their progress for a number of reasons, including focusing physician education and justifying continued funding from organizational leadership.
Coding for knee arthroscopies can be challenging, especially when procedures are performed in multiple compartments of the same knee. Read about anatomy and coding details required to accurately report these procedures.
Learn how to emphasize the clinical value of the documentation and establish policies and training that support medically and legally sound notes while making the best use of physicians’ time.
Pay close attention to new CPT documentation and coding guidance for reporting radiological imaging. For example, a new paragraph titled “Imaging Guidance” in both the surgery and medicine guidelines advises that even when imaging guidance or supervision are included in a surgical procedure code, you must still follow the radiology documentation requirements in the CPT manual.
