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.

 

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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