Melissa Koehler, RHIA, CHDA, CDIP, CCS, CCS-P, CCDS
Melissa Koehler is a HIM professional with substantial coding, auditing, and CDI experience. With an HIM career spanning 25 years, she’s served in various production and leadership roles in several HIM disciplines of facility coding and leadership roles. Melissa is the audit manager for the Coding Education Program department at Baylor, Scott, & White Health. She has served on several committees on the national, state, and local levels including local association president 2017-2018, and Tennessee Health Information Management Association (THIMA) Data Analytics & Informatics Committee chair 2017-2019. She represents the state of Tennessee with AHIMA as Coding Roundtable Coordinator. National level involvement includes 2016 Standards for Ethical Coding Taskforce, and Clinical Terminology & Classification Practice Council from 2017-2019. She currently serves on AHIMA’s CDI, Quality, and Revenue Management Practice Council. She has spoken on various coding and CDI topics at the local, regional, and state levels. On a national scale, she was a keynote speaker for the 2017 AHIMA CDI Summit. Melissa completed her Associates of Applied Science in Health Information Technology at Walter’s State Community College and earned a Bachelor of Science in Health Informatics & Information Management from The College of Saint Scholastica.
Ginny Ward, RHIT, ACDIS Approved CDI Apprentice
Ginny Ward has been in the HIM profession since 2006 after graduating from WCJC and obtaining her RHIT. She started out in Ancillary coding with progression to ED, Ambulatory Surgery, Observation, Inpatient and currently auditing. She started working at Scott and White in 2010 as an outpatient coder and eventually moved into inpatient coding. During the Scott and White merge with Baylor she began inpatient auditing. She transitioned onto the Coding Education team where she currently performs focus audits including Patient Safety Indicators (PSI), Hospital Acquired Conditions (HAC), Preventable Adverse Effects (PAE) and Potentially Preventable Complications (PPCs) in addition to the Auditor Routine Monthly Audits (ARMA). Most recently in 2019, she received her certificate as an ACDIS-Approved CDI Apprentice, with plans to obtain her CCDS.
This presentation will cover the ICD-10-CM guidelines for reporting complication codes, documentation examples needed to support code assignment, and the when, how, and why of querying when the documentation is not clear. It will also provide a review of how ICD-10-CM code assignment for complications and qualifying diagnosis codes can affect quality data such as hospital acquired conditions (HAC), patient safety indicators (PSI), potentially preventable complications (PPC), and the impacts to an organization for incorrectly assigning these codes.
Case scenarios for code assignment and discussion will also be provided.