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. 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: [email protected] Rachel Mack’s email: [email protected] Subscribe Today! Apple Podcasts Amazon Podcasts Android Spotify RSS Feed