Documentation for Specific Topics, Diagnoses, Procedures: Solid Tumor Neoplasms

Outline:

Section 1: Introduction

Course Overview

Section 2: Neoplasm Documentation

Importance of Clinical Documentation

Locating Neoplasm Documentation

Medical Necessity Criteria

Review

Key Takeaways

Section 3: Documenting Neoplasms

Neoplasm Terminology, Characteristics, and Behavior

Identifying Sites and Relationships

Review

Key Takeaways

Section 4: Neoplasm Coding and Documentation Requirements

Neoplasms: Problematic Terminology

Neoplasm Coding and Documentation

Neoplasm Staging

Associated Conditions and Complications

Treatments and Complications

Review

Key Takeaways

Section 5: Neoplasms Coding Guidelines

Neoplasm Sequencing

Neoplasm Sequencing Exceptions

Review

Key Takeaways

Section 6: Neoplasm Reimbursement and Quality Reporting

Documentation, Reimbursement, and Quality Reporting

Review

DRG Validation

Chemotherapy, Immunotherapy, and Radiotherapy MS-DRGs

Review

Key Takeaways

Section 7: Conclusion

Course Summary

Course Contributor(s)

Resources

References

Sarah is a Subject Matter Expert/Writer for Relias's Revenue Cycle and Coding online education. Sarah is credentialed by AHIMA as a Certified Coding Specialist (CCS) and Certified Coding Specialist Physician-based (CCS-P), as well as an approved ICD-10-CM/PCS Trainer. She is also credentialed by AAPC as a Certified Professional Coding Instructor (CPC-I), a certified professional coder (CPC), a certified outpatient hospital coder (COC), and a Certified Risk Adjustment Coder (CRC), with specialty certification in Evaluation and Management Services (CEMC). Sarah extensive experience in both professional and facility ICD-10-CM/PCS, CPT, and HCPCS coding, education, auditing, and revenue cycle management. She has clinical experience as an Emergency Medical Technician (EMT) and Medical Assistant (MA) and has served as Director of Physician Billing and Reimbursement for a regional health system, Manager of Coding and Compliance for a hospital and cancer center, and Business Manager of Physician Practices at a teaching hospital, as well as a coding auditor and consultant. Sarah has also authored several coding textbooks, and other instructional resources.

Dr. Daniel Migliaccio is currently a Clinical Associate Professor of Emergency Medicine and Director of Emergency Ultrasound as well as the Ultrasound Fellowship Director at the University of North Carolina at Chapel Hill. He completed his residency in Emergency Medicine at Stanford University. During Residency, Dr. Migliaccio was able to obtain an Honors Certificate in Medical Education from the Clinical Teaching Scholars Honors Program. He was also fortunate enough to be able to focus on his ultrasound skills, leading to an award for Outstanding Achievement in Ultrasound. Dr. Migliaccio is passionate about medical education, point-of-care ultrasound, and optimizing patient care using current literature. He is currently board-certified in point-of-care ultrasound with a Focused Practice Designation in advanced point-of-care ultrasound through the American Board of Emergency Medicine and is enthusiastic about promoting Emergency Medicine and patient care nationally. Recently, he has obtained a certificate for course work and training with Diversity, Equity, and Inclusion through the University of North Carolina School of Medicine and is passionate about providing unbiased, equitable patient-centered care.