Thursday Mar 28, 2024

Issues around elective surgery documentation, Part 2

This episode continues the series on challenges and issues involving correctly documenting elective surgeries. A leading expert provides practical guidance and considerations that enable you to be correct in documenting these patients in order to improve care and maximize reimbursement.


Tomas Villanueva, DO, MBA, FACPE, SFHM
Senior Principal, Performance Improvement Consulting


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


Show Notes:

[00:34] Dealing with preoperative infections

[01:56] Percentage of elective surgery patients who develop sepsis—with 25% mortality

[03:45] Accurately coding to avoid a PSI 13 being charged to your practice/organization

[05:34] Do not miss a Present on Admission case

[07:30] Need for CDI specialists to collaborate with quality (the “dotted line”)

[08:50] Issues around PSI 7


Links | Resources:

To contact Modern Practice:

Rachel Mack’s email:

“Costs of Postoperative Sepsis: The Business Case for Quality Improvement to Reduce Postoperative Sepsis in Veterans Affairs Hospitals” (JAMA): Click Here


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