Thursday Aug 31, 2023

Challenges in Documenting Spinal Surgery, Part 3

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.


Tomas Villanueva, DO, MBA, FACPE, SFHM
Senior Principal
Clinical Operations and Quality

Rachel Mack, MSN, RN, CCDS, CDIP, CCS, CRC
Consulting Director
Clinical Documentation Improvement


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:

Rachel Mack’s email:


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