• Challenges in documenting spinal surgery, Part 3

  • Nov 14 2024
  • Length: 15 mins
  • Podcast

Challenges in documenting spinal surgery, Part 3

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  • Summary

  • 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.

    Host: 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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