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Accuracy and Completeness of Clinical Coding Using ICD-10 for Ambulatory Visits

Abstract

This study describes a simulation of diagnostic coding using an EHR. Twenty-three ambulatory clinicians were asked to enter appropriate codes for six standardized scenarios with two different EHRs. Their interactions with the query interface were analyzed for patterns and variations in search strategies and the resulting sets of entered codes for accuracy and completeness. Just over a half of entered codes were appropriate for a given scenario and about a quarter were omitted. Crohn’s disease and diabetes scenarios had the highest rate of inappropriate coding and code variation. The omission rate was higher for secondary than for primary visit diagnoses. Codes for immunization, dialysis dependence and nicotine dependence were the most often omitted. We also found a high rate of variation in the search terms used to query the EHR for the same diagnoses. Changes to the training of clinicians and improved design of EHR query modules may lower the rate of inappropriate and omitted codes.

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Introduction

The almost seventy thousand codes that comprise the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10-CM) are far more detailed than those in the preceding version that clinicians in the United States were working with since the late 1970s.1 This new level of complexity is expected to not only facilitate documenting and reporting causes of mortality and morbidity but to also extend the ability to identify and manage clinical processes with information technology by identifying changes in medication management and by monitoring data for health maintenance and preventive care purposes.2 Highly granular and more accurate data are also indispensable for rapidly expanding secondary uses such as detecting healthcare fraud, developing patient safety criteria, setting healthcare policy and developing public health initiatives, improving clinical performance and, crucially, allowing large-scale analyses for medical research. Codes are also essential in clinical care for phenotyping and predictive modeling of patient state.3 The transition also has significant implications on reimbursement from health care insurers. Diagnostic codes may be used to determine the severity of illness of a provider’s patient population and affect payment rates with newly adopted payment models.

Codes that previously could not differentiate between several types of diabetes, for example, are now refined to capture important distinctions but require clinicians to add to their documentation causal underlying conditions or whether the disease was induced by drugs.4 A more detailed description of laterality and location in the patient’s body is also a newly added specification. The previous emphasis on organs and disease that prioritized physician-oriented content is expanded to also cover human responses to disease that are necessary for advanced nursing and long-term care.5

Many electronic health record (EHR) systems integrate clinical documentation and billing information and provide cross-mapping between primarily care-oriented and reimbursement- or report-oriented data. Problem lists, for example, need to conform to standardized vocabularies based on ICD-10 or SNOMED codes for the CMS EHR Incentive Program known as Meaningful Use.6 EHRs may employ their own proprietary reference terminologies that allow to search for and display diagnostic and other concepts in forms that clinicians find customary and meaningful while maintaining mapped connections in the background to more or less granular codes intended for reporting, financial or automated decision-support purposes. Typically, a clinician adding a coded term to a problem list or a fully-qualified ICD-10 code to a billing record starts with typing one or more words, an abbreviation or a string of characters into a free-text query field. A record search engine within the EHR then returns results based on their relevance to the search string and ranks them in a list according to differentiating logic for complete word or partial word matching. For example, a search initiated by typing “esrd” may return many diagnostic codes related to end-stage renal disease. Further search through the results may be necessary, either by reading the list or by repeating the search with different terms, to find the exact code appropriate for the intended purpose. More sophisticated systems provide automated assistance with this refinement by using “wizards” or other support interventions to help locate the target diagnosis quickly.

The almost four-fold increase in the number of diagnoses in the current coding system presents a formidable challenge to computer engineers and designers to develop algorithms and human interfaces that can, in the same short time available to clinicians and medical coders in routine practice, query, compare and select the best descriptive diagnostic or other code in the vastly expanded field. A recent survey of perspectives that coders and physicians had about the practical usefulness of ICD-10 showed that most agreed on the need for computer-assisted coding.7 If the query process is not effective, however, clinicians may find themselves facing a choice between accurate and “close enough” coding when time constraints preclude further refinement of the process. This learned behavior would directly contravene the goal of improved and precise documentation of clinical care made possible with the ICD-10 system.

This study was intended to describe search behavior of clinicians using tools available in large EHR systems who were entering ICD10 codes. Our objectives were to observe interactive behavior that may contribute to incomplete or inaccurate coding and to analyze variations in coded diagnoses for standardized clinical scenarios. Findings of systematic errors or difficulties in completing the coding task may help inform or revise training that clinicians currently receive and to provide evidence and insight for improvement to electronic coding and indicate a need to revise the coding system itself.

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Methods

The study was designed as a simulation of a clinical documentation task where clinicians used standardized case scenarios to enter diagnostic codes into the EHR. We asked 23 physicians to read short vignettes describing a variety of ambulatory visits and then enter relevant ICD-10 codes into a mock patient record. Seventeen participants completed two sets of three scenarios, using each set for a different EHR; six completed only one set, using EHR 1, due to technical reasons. In total, there were 40 completed sets: 23 on EHR 1 (12 Sets A and 11 Sets B), and 17 on EHR 2 (10 Sets A and 7 Sets B). The order of set completion (A vs. B) alternated to minimize possible learning bias.

EHR 1 was a commercial and EHR 2 an internally-developed clinical information system. Both required an initial entry of a search term into a free-text field that returned a list of ICD-10 codes with descriptions. If the target term was in the results they could simply select it or further refine the list by entering a different search string. Decision support interventions were available on both systems and were either triggered automatically for a subset of diagnoses in EHR 1, with an option to disregard, or were designed as a part of the entry process on EHR 2.8 Participants choosing to use decision support on EHR 1 could click on modification terms in pre-determined sets and an algorithm would refine the results accordingly to a single ICD10 code. Initial search on EHR 2 returned a list filtered by patient parameters such as age and gender that could be also modified by selecting answers to term-specific questions (e.g., Laterality? Left, Right, etc.) Both systems used algorithms and branching logic during the guided-search phase to refine result lists and suggest fully specified billable codes. For example, if “otitis media” was the initially entered search term, the support intervention would show subsets of optional terms for laterality, chronicity and recurrence. The visual presentation of these terms, their number and content were different for each system.

Practicing ambulatory clinicians (22 physicians, 1 physician assistant) were recruited through internal email advertising as a sample of convenience. Twenty-one (91%) had ten or more years of professional experience, sixteen (65%) as primary care providers and seven as specialists. Ten (44%) used EHR 1 for 6 months or more, twenty-one (91%) daily in practice. All were proficient in using EHR 2 as it served as the primary ambulatory record system prior to an institution-wide transition to the commercial system. The ICD10 requirement went into full effect in the hospital during the transition period and clinicians have therefore been entering codes with both EHRs for approximately the same time. Both systems had proprietary interface terminology and participants did not use any other sources such as ICD10 on the web.

Participants completed the task individually in the presence of an experimenter on a single workstation that was connected to both EHR systems. They were instructed to read each scenario and then find relevant codes according to their own clinical judgment, and to use their preferred strategy in order to best simulate authentic behavior. The number of codes expected for each scenario was not explicitly stated, only that more than one may be necessary. Interactions of clinicians with the two systems were recorded into an audiovisual media file using Morae9 screen-capture software running in the background. The recordings of full screens and verbal comments were later analyzed.

Scenarios and accuracy-rating criteria for diagnostic codes

Study scenarios were taken verbatim from interactive case studies made available by the Centers for Medicare & Medicaid Services (CMS) on their Road to Ten website.10 Since the CMS recommendations for the correct ICD-10 codes were only one example of proper coding, we developed rating criteria for the appropriateness of codes in order to accommodate other correct coding options. Two physicians (HZR, EAD) independently reviewed codes entered by the participants and rated whether they were appropriate in the context of each scenario. They reached consensus on disagreements through a series of discussions. Ratings were based on two criteria: clinical accuracy and completeness. Although the rating was binary (appropriate or not), the reviewers acknowledged the potential range of responses due to variations in clinical judgment and in the complexities of the structure and intent of the ICD-10 coding system. A code rated “appropriate” could be clinically accurate but incomplete in a way that did not alter the diagnosis or miss clinically crucial information. For example, indicating that allergic rhinitis was seasonal but not explicitly including the causative agent of pollen, or documenting tonsillitis or pharyngitis for a patient with an inflamed pharynx with tonsillar exudate, would be still considered “appropriate”. However, codes without clinically significant information would not. This would include omitting streptococcus as the etiology of tonsillitis in a case where the rapid strep test was known to be positive, or not specifying large intestine in a case of Crohn’s disease complicated by colonic abscess.

Как правильно выбрать проститутку и на что стоит обратить внимание?

Пользуюсь услугами девушек (правильнее называть их так) года с 2009, поэтому позволю себе дать кое-какие советы. 

1. Единственный сайт, которому стоит доверять - интимсити. Полное название легко серфится в гугле, ссылку давать не буду, дабы не сойти за сутенера и не рекламировать бесплатно. На этом сайте реальны 95% фотографий (в отличие от досуга, русдосуга и тому подобной лабуды с призывными названиями). Как правило, под анкетой девушки стоят оценки посетителей. Обращайте на это пристальное внимание: если оценок нет совсем, или оценки пишутся анонимами - с высокой долей вероятности вас на месте событий ждет разочарование. 

2. Когда определились с сайтом, встает....увы, встает пока только вопрос, ехать к ней или приглашать к себе. Как правило, подавляющее большинство девушек в наше время работает в апартаментах (читай, принимает у себя дома). На выезд древнейшая профессия собирается с вполне понятной неохотой: никому не улыбается переться на другой конец города в незнакомую квартиру, где девушку может ждать всё, что угодно. Выезжают куда-либо либо отчаянные матюрки довольно потасканного вида (которые вас вряд ли дико возбудят), либо горластые негритянки (с которыми лучше не связываться, почему - опишу ниже), либо совсем уж вторсырье. 

Впрочем, если вы живете внутри хотя бы метрокольца, не говоря уже о Садовом, а ценник у девушки начинается от 5000 рублей за час, то, скорее всего, приедет к вам именно тот, кто изображен на фото. 

3. Допустим, решено ехать в апартаменты. Чтобы понять, фейковое фото или нет, достаточно, как было сказано выше, почитать оценки под анкетой. Если их хотя бы больше трех, и все они подписаны клиентами с изрядным количеством "ходок" - смотрим на ценник. 

Минимальная адекватная цена на апрель 2016 года составляет 2000 рублей за час. Всё, что ниже - тревожный сигнал. В наше время, когда, скажем, бутылка вина стоит в среднем 300-400 рублей, трудно представить себе очаровательную нимфу, готовую предоставить себя вам полностью на час за полторы тысячи рублей. Видите такую цену - будьте готовы приехать в гоблинарий с таджичками или просто попасть на персонажа, который будет так же похож на фото, как Нокиа3310 - на пятый Айфон. 

Нормальная цена - 2500-3000 рублей. 3500 и выше - категория "А": апартаменты в центре, ухоженное тело, свежесть и упругость. За 5000 и выше, если позволяют финансы, можно снять девушку, ничем не отличающуюся от порнозвезды. Это не пафос и не громкие слова. Есть ещё женщины в русских селениях.  Trust me. 

Если ехать куда-то очень ломает, ну или вы человек стеснительный, а финансы позволяют пригласить ночную бабочку к себе, помните, что выезжают девушки, как правило, на 2 часа. Стоит это минимум 7000 (обычно 8000) рублей, плюс деньги на такси. Феи очень любят поиграть в русскую народную забаву "подоить клиента", поэтому вам решать, давать денег или не давать. В зависимости от настроения или степени культуры стоящей перед вами проститутки её можно послать, а можно и поиграть в доброго дядю. Только учтите, что гейши в стоимость выезда стоимость такси закладывают так и так. А едут при этом на метро. Так что если енг уже дымится, а девушка воркует и говорит, что она будет минут через пять - не верьте. Можно пока посмотреть порнушку, глотнуть алкоголя, выкинуть мусор, погулять с собакой, пропылесосить, снова глотнуть алкоголя, поесть, искупаться и даже поспать: приедет жрица любви к тебе из своего гетто не раньше, чем через полтора часа. 

Никогда не снимайте негритянок, если, конечно, вы не ярый фетишист и не куклуксклановец. Причин несколько. Первая - нигры не говорят по-русски или говорят очень плохо. Если у вас трудности с владением иностранными языками - могут возникнуть проблемы. Второе - с нашими проще объясниться, договориться, посмеяться и пыр и дыр. Нигры суть иностранцы со всеми отсюда вытекающими. Считай, что привели живую куклу, которую тебе ещё надо уложить. Но в отличие от покорных кукол-таек, нигры - третье! - очень базарные и вечно всем недовольны. Начинают включать дурочку, якобы не понимая, чего от них хотят, отказываются делать то, чего от них хотят, начинают размазывать слезы по нагуталиненным щекам, в общем, если хотите получить испорченный вечер и неслитые баллоны - заказывайте черненьких.  

4. Внимательно изучите анкету. Очень часто цена означает только классический секс без причуд. За "допы" (дополнительные услуги) нужно платить. Анальный секс, минет без презерватива и тому подобные прихоти обойдутся от 500 до 1000 рублей за каждую (в зависимости от жадности феи). Ещё раз посмотрите на отзывы - они могут быть написаны в 2011-2014 годах, а за время пути "собака могла подрасти". Проституточий бизнес - дело нелегкое, прежде всего для тела девушки и морды её лица. У меня пару раз были случаи, когда, соблазнившись фоткой, выезжал к сочным милфам, а встречала меня женщина скорее из категории "granny".  Впрочем, от ошибок никто не застрахован, ибо путь дона напоминает перемещение сапера по минному полю: повезет - не повезет. 

5. Последний этап - звонок. Тут вы поймете всё сами. Слышите хамское отношение - кладите трубку. Слышите воркование в духе "зая, ты подъезжай, тут рядом" - кладите трубку, скорее всего, это диспетчер, который приведет вас в салон. Индивидуалки разговаривают спокойно и четко: хамить им смысла нет - клиента потеряют, рассусоливать тоже - время дорого. Вам тоже не стоит им хамить. Не стоит им "тыкать".  Вообще забудьте о многих стереотипах: как написано выше, проститутками зачастую становятся нормальные женщины. И чем уважительнее вы к ней отнесетесь, тем больше бонусов получите в ответ. Это не значит, что к девушке нужно являться с цветами - достаточно хорошего разговора по телефону и максимум человеческого отношения в постели. 

How To Choose The Perfect Fashion Store?

Are you interested in revamping your wardrobe? If you are looking to update the clothing or clothing accessories that you own, you may be interested in incorporating some of the latest fashion trends into your wardrobe. If you are, you will need to find a fashion store to shop at.

When it comes to finding a fashion store to shop at, you have a number of different options. Before examining those options, you need to remember that fashion stores are operated in both storefront locations and online. If you are looking for an online fashion store, you may want to think about performing a standard internet search. If you are looking for a storefront store to shop at, you may want to think about visiting your local shopping mall, using your local phone book, or using online business directories.

Although the above mentioned searching methods are all great ways to go about finding a fashion store and a good number of them at that, you never really know what type of stores you will come across. That is why you will actually want to do more than just find a fashion store to shop at; you will want to choose one to shop at. When it comes to choosing the perfect fashion store to update your wardrobe, there are a number of important factors that you may want to take into consideration.

One of the many factors that you may want to take into consideration is the stores in question. Fashion stores come in a number of different sizes, shapes, and styles. For instance, there are clothing stores that are designed for plus sized women, teenagers, athletic men and women, and so forth. In addition to examining your gender and your size, you may also want to take the type of clothing fashions that you would like to buy into consideration. Are you mostly just looking for work clothes or do you want a combination of work clothes and causal clothes? Knowing what type of clothing and fashion accessories you would like to buy is very helpful when it comes to finding the perfect fashion store for you and your needs.

Cost is another factor that should be taken into consideration when choosing a fashion store to shop at. A large number of the fashion stores that carry the latest and greatest fashion trends are likely to be fairly costly. If you have an unlimited amount of money to spend on a new wardrobe, this may not necessarily be a problem for you. However, if you are on a budget, you may want to examine the fashion stores that you are interested in shopping at and their average sale prices. If you are able to do a little bit of research online, even for storefront store, you may be able to save yourself a considerable amount of time.

Another factor that you may want to take into consideration is location. Fashion stores are located all across the county and even some are located in small cities and towns. However, if you are looking for some of the clothing pieces and fashion accessories that may be found on the runways of New York and Paris, you may not be able to find those items in your local fashion stores. For that reason, it is important that you examine the location of the fashion store or stores that you would like to shop at. Of course, you will likely want to stay locally, but if you are serious about updating your wardrobe to include the latest trends in fashion, you may want to make arrangements to travel to a well-known fashion store, even if it is a few hours away.

The above mentioned factors are just a few of the many ways that you can go about finding the perfect fashion store. If you are not pressed for time or if you would like to make a fun adventure out of buying a new wardrobe for yourself, you may want to start hitting up as many fashion stores as you can find. Somewhere along the way, you are sure to find the perfect one, if not more.

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Four Factors to Choosing Eyeglass Frames

You don’t need to be a fashion expert to find eyeglass frames that look great on you. Eyeconic makes finding the right frames simple. Use the following four tips to find the frames that work best for your style.

1. Face Shape
   Is your face round, oval, square, diamond or heart-shaped? The shape of your face will help you determine which frames enhance your look.
   • Round Face: Eyeglass frames that are square or rectangular tend to be wider than a round face. This quality can enhance your face by making it appear slimmer and longer, adding balance to your round features.
     Frames to Avoid: Rimless frames, round frames and small frames will accentuate the roundness, making your round face look even rounder.
   • Oval Face: Frames that suit an oval face have a strong bridge, are wider than the broadest part of the face and are geometric in shape.
     Frames to Avoid: Eyeglasses that are overlarge and cover up more than half of your face will throw off the natural balance and symmetry of the oval face.
   • Square Face: Eyeglasses that soften the angularity and sit high on the bridge of the nose look best on square faces. Oval or round eyeglasses will balance and add a thinner appearance to the angles of a square face.
     Frames to Avoid: Angular and boxy eyeglass frames will sharpen and draw attention to your angular features, making a square face appear bulky.
   • Diamond Face: Play up a narrow forehead and chin with eyeglass frames what sweep up or are wider than the cheekbones, such as cat eye glasses and oval frames. These frames will accentuate your cheekbones and delicate features.
     Frames to Avoid: Boxy and narrow frames will accentuate the width of your cheeks, drawing attention to your narrow features rather than enhancing them.
   • Heart-Shaped Face: Frames that balance the width of the forehead with the narrowness of the chin are ideal. Eyeglasses with low-set temples and bottom heavy frame lines will add width to that narrower part of your face. Round eyeglasses or square eyeglasses with curved edges will help draw attention away from a broad, high forehead.
     Frames to Avoid: Steer clear of any style or color of frames that draws attention to the forehead. This includes frames with decorative temples or embellished tops.
   The key to finding the right frames is to remember that opposites attract. Select eyeglasses that contrast from your facial contours and bring symmetry and balance to your prominent features. At Eyeconic you can try on hundreds of eyeglass frames virtually to see which styles complement your appearance.


2. Consider Colors That Match Your Skin Tone
   Just as the shape of your face helps determine which frames look best, so does your skin tone. More important than hair color and more decisive than eye color, skin tone sets the tone for high fashion frames. Select a shade closest to your skin tone:
   • Warm Skin Tone
     If you have a yellow, bronze or golden cast to your skin, you have a warm complexion. Stay away from contrasting colors such as pastels. White and black frames are not flattering either. Instead, the best frame colors for you are light tortoise, browns shades, gold or honey, beige, and olive green.
   • Cool Skin Tone
     If your skin has pink or blue undertones, you have a cool complexion. Avoid colors that wash you out and instead reach for frames that are silver, black, dark tortoise, pink, purple, blue, mauve and gray.
3. What's Your Lifestyle?
   There are eyeglass frames for every way of life! Think about the activities you will do while wearing your eyeglasses. If you're active, Eyeconic offers Flexon frames which can twist and bend without breaking. Need gaming glasses? Gamers can choose from a wide selection of stylish frames that enhance the gaming experience. When impressing the big wigs at the office, you can accessorize your business savvy with sensible style. At Eyeconic you'll find frames with a functionality that matches your lifestyle.


4. Fit Frames to Your Personality?
   The frames you wear can say a lot about your personality. You can have a pair of glasses that showcase your fun loving side on the weekends and a pair that emphasizes your get down to business tone during the week. Adorn your face with your favorite color (as long as it doesn’t clash with your skin tone) or detailed embellishments and flare. Choose either one style of frames to express your personality or have a small collection of frames on hand to easily alter your appearance to suit your mood.

Ремонт на практике: как самостоятельно построить межкомнатную стену

Многим приходится сталкиваться с возведением межкомнатных перегородок. Это актуально как для новых квартир со свободной планировкой, так и для старых домов – в том случае, если вы хотите увеличить площадь комнат или изменить конфигурацию помещения. Чтобы жить в квартире было действительно комфортно, необходимо сделать новые стены не только прочными и надежными, но и шумопоглощающими. Рассматриваем варианты строительных материалов, из которых можно сделать идеальную межкомнатную перегородку.

1. Кирпич

Это один из самых популярных материалов для возведения новых стен. Как правило, при бюджетном ремонте используют недорогой и прочный силикатный кирпич. Из него получаются теплые, прочные стены с хорошей звукоизоляцией, к тому же им можно придать нестандартную закругленную форму, если это предусматривает ваш дизайн-проект. Однако такие стены имеют свои недостатки. Во-первых, кирпичная кладка – процесс грязный и трудоемкий, работа займет довольно много времени и обойдется недешево. Во-вторых, она съедает драгоценные сантиметры полезной площади и создает дополнительную нагрузку на перекрытия.

Совет InMyRoom: как мы уже говорили, на возведение кирпичной стены уходит много времени. Поэтому, если вы хотите закончить ремонт по плану, заранее выделите достаточно времени на постройку кирпичной перегородки.

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2. Газо- и пенобетонные блоки

Из газо- и пенобетонных блоков межкомнатную перегородку можно построить быстро, бюджетно и довольно-таки просто. Прежде всего потому, что блоки имеют большой размер, и сделанные из них стены не требуют дополнительного оштукатуривания – поверхность и так получается ровной. Лучше всего использовать блоки толщиной не меньше 75 миллиметров: они прочные (например, способны выдержать книжную полку) и обеспечивают хорошую звукоизоляцию. Еще один неоспоримый плюс этого стройматериала – из него можно строить арочные проемы без применения усиливающих конструкций. 

Совет InMyRoom: стены в ванной или санузле лучше возводить из пенобетона. Газобетон – пористый материал, поэтому поглощает слишком много влаги.

3. Пазогребневые гипсовые блоки

Одно из важных преимуществ этого материала – его нетоксичность: блоки делают из экологичного гипса, цемента и легких наполнителей. Кроме того, они отличаются ровной поверхностью и геометрической точностью – так что стену не нужно штукатурить под финишную отделку. Среди отрицательных свойств этого строительного материала – низкая влагостойкость. Поэтому, если вы планируете возводить стены в санузле, выбирайте специальные влагостойкие гипсовые блоки, которые подойдут для ванной. Также к недостаткам можно отнести высокую стоимость гипсовых блоков.

Совет InMyRoom: пазогребневые гипсовых блоки – довольно хрупкий материал. Поэтому будьте осторожнее во время разгрузки, а при монтаже используйте резиновый молоток.

4. Гипсокартон

Самый доступный материал, из которого можно соорудить межкомнатную стену, – это гипсокартонный лист, который монтируют на стальной каркас. Работа занимает совсем немного времени, что особенно важно при ограниченных сроках ремонта. Что особенно важно, стены получаются безупречно ровными, и их можно сделать более звукоизолированными, если заполнить пустоты специальным материалом. Для ванны и санузла подойдет влагостойкий гипсокартон со специальной пропиткой. Однако гипсокартонная межкомнатная перегородка имеет свои недостатки: она не очень прочная, и без дополнительного усиления не выдержит даже обычную книжную полку.

Совет InMyRoom: чтобы сделать такую перегородку более звукоизолированной, стену нужно монтировать из двух слоев гипсокартона. А в середину заложить утеплитель – минвату, эковату, пенопласт или опилки.  

21 Ideas for a Frugal (Not Cheap) Wedding on a Budget

1. Avoid guest list bloat.

Although you might be tempted to throw everyone you know on your guest list, that isn’t always a great idea. With each addition you make, you’re adding additional costs while also making your wedding less intimate.

To a degree, this was a trap we fell into with our own wedding – our guest list grew and grew to the point where we invited people that we didn’t know well simply because we felt obligated.

To save as much as you can, try inviting fewer people and making the event more intimate. Start by whittling your list down by 20%, then another 20%. Then see if you’re happy with it.

2. Ask for wedding help instead of wedding gifts.

We were lucky that several of our friends and family had musical talent, so they were able to provide musical accompaniment for our ceremony. We also have a close friend who’s an extremely skilled amateur photographer, and he was willing to photograph our ceremony as our wedding gift. Then, after the ceremony, he provided high-quality digital images of everything.

Asking family and friends to offer help or services that align with their talents in lieu of a gift is a great way to keep your wedding on a budget.

3. Hold the ceremony at home, or outdoors.

Renting a building or function hall for your ceremony and reception can be very expensive. Instead, consider using your own home (or the home of a parent) for your ceremony, or perhaps a public park with a beautiful view.

In each case, you can also have your reception outdoors, creating a picturesque, memorable ceremony while eliminating the cost of renting a venue.

If you go the outdoor route, however, it’s best to have a back-up plan in case of bad weather; you don’t want to get married in a downpour that leaves all your friends and family soaked. That might mean renting a sturdy tent if rain is forecast, or a few industrial fans if it’s an extremely hot day — or simply stuffing everyone inside the house to wait out a storm.

• Related: Check Out These Beautiful, Affordable Wedding Venues

4. Do the catering yourself, or hire a family-owned restaurant.

For our wedding, we handled our own food preparation and catering with a lot of help from my wife’s family. This drastically reduced the food costs for the ceremony.

If this isn’t your forte, look around your community for a family-owned restaurant and ask the owners directly to cater your wedding. Family-owned restaurants are always the first place to check – they will almost always go the extra mile to make your wedding special and are generally more understanding of your particular budget needs.

5. Go minimal with the flowers.

Instead of spending boatloads of money on flowers that will die shortly after the reception, keep it simple but elegant — for instance, a single rose for each bridesmaid and a very small bouquet for the bride. If you know someone with a rose bush, you can actually make your own bouquets the day before the ceremony by cutting the roses yourself and trimming away the thorns.

Another cheap wedding idea – go with fake flowers instead. It’s likely that no one will even notice, and you could save a bundle by making the arrangements yourself well ahead of time.

6. Skip the groomsmen and bridesmaid gifts.

While it’s considered customary to give gifts to your groomsmen and bridesmaids in some circles, it isn’t always necessary. Instead of buying gifts they may not even want or enjoy, consider writing them a special note to say “thanks” instead. If your friends know that you’re trying to have a frugal wedding, they will understand.

7. Make your own invitations.

With a quality home printer and some time, you can make very classy invitations on your own. My wife and I picked up a simple blank invitation kit on sale at Staples and made our own invitations to our wedding. No pictures or anything – just a very classic font and simple text. It looked stylish and didn’t cost us much at all.

Sites like VistaPrint.com also offer cheap wedding invitations you can order from the comfort of your home. Their options aren’t too fancy, but they’ll certainly do the trick. You can even hire a freelance graphic designer to whip up a custom invitation for you on Fiverr for pretty short money (starting at $5).

• Related: How to Find Affordable Wedding Invitations

8. Borrow stereo equipment or use yours from home.

Rather than hiring a DJ, just use your own home stereo equipment, or equipment you borrow from a friend. Put speakers around the dance floor area – there’s no need to spread them around the entire reception room. Create a playlist on your iPod that features a few hours’ worth of your favorite songs – or see if you have a friend who might want to make a playlist for you. Choosing your own songs is a great way to personalize your entire experience.

9. Stock the bar yourself.

Alcohol is a big expense when it comes to a lot of weddings, and it’s also a big variable you can play around with to cut costs. Instead of opting for a full open bar, for instance, you can save money offering just beer and wine, or a free cocktail hour followed by a cash bar.

If you do rent a function hall, ask if they’ll let you supply your own alcohol instead of using the venue’s, which can be a big money-saver. Look for a discount liquor store in your area, and stock up on the basics: red and white wine and a few types of beer at the very least. If you want to offer a full bar, pick up the standard liquors like vodka, gin, rum, and whiskey, plus a few mixers and soft drinks like sodas and juice.

Keep in mind that while it’s more cost-efficient to buy a keg of beer instead of cases, any leftover beer will go to waste, whereas you can store excess bottles for months. And that’s helpful, since it’s a good idea to overestimate — you don’t want to run out of drinks halfway through the reception.

10. Display ‘vendor cards’ in exchange for reduced rates.

If you’re hiring people to provide services for your reception (musicians, a DJ, florists, caterers, photographers, etc.), offer to advertise for them in exchange for reduced rates.

At the reception, put a small card by each person’s place setting that lists the businesses responsible for each service at the wedding, along with their contact information. Since this tends to be very effective advertising, many businesses will happily provide services at reduced rates in exchange for this opportunity.

11. Contact the local university.

If you’d like live musical accompaniment for the ceremony (and perhaps for the reception), one place to look for lower-cost musicians is your local university’s music department.

Contact them and ask if there are any students who are studying a particular instrument or vocal work and see if they’re available to provide music for a wedding. It can help them develop their resume and save you on this typically pricey part of your wedding.

This goes for photographers as well — if there’s an art school or photography program at your local college, see if there are any talented students or recent grads who would be willing to photograph your wedding at a discount for the portfolio-building experience and exposure they’d receive.

12. Price shop for decorations – and consider buying used.

Michael’s, Paper Warehouse, and Hobby Lobby all have sales throughout the year. If you know what you’re looking for ahead of time, you can simply wait until it goes on sale and “pounce” when the time is right.

Meanwhile, you can also consider buying used centerpieces and decorations. Recent brides often sell their decorations on sites like craigslist.org, and you can save a bundle of money — and effort — going that route.

13. If you’re getting married in your own church, ask the ladies’ auxiliary for help.

Most churches have a women’s organization that is very happy to help with wedding preparation in exchange for a small donation. Get them involved – they can take a lot of worry off your shoulders for a relatively low price.

At our wedding, the “church ladies” were a great help with church decoration and other helpful things on the day of the ceremony.

14. Buy dresses off the rack – and on sale.

If you want to save on bridesmaid dresses, try to avoid ordering custom dresses altogether. Instead, head to a few stores with dresses on sale and see if you can all find something “off the rack.”

This works best if your colors are chosen ahead of time and if the store you’re shopping at carries plenty of sizes. To minimize spats within your wedding party, you can also shop ahead of time and only have them try on dresses you already approve of.

Another cheap wedding idea: Instead of buying new dresses, have every bridesmaid wear a particular color dress they already own.

15. Rent tuxedos as a group, or simply wear matching suits.

Unless you have a specific reason for owning a tuxedo (and few people do), you should rent one. It’s often useful to rent the tuxedos as a group through the same business, as you’ll often get a group rate.

If you don’t want to go the tuxedo route, you can also have all of your groomsmen wear a black suit from home or other matching formalwear.

16. Choose affordable wedding rings.

Wedding bands are traditionally an important part of the marriage ceremony, symbolic of your commitment to each other. That doesn’t mean they have to cost you a fortune.

A typical 14-karat wedding band can cost upwards of $1,000, and wedding website TheKnot says American couples tend to spend about 3% of their overall wedding cost on the rings (plus thousands more on an engagement ring). If you’re trying to pull off your wedding on a budget, this is an area where you can trim costs pretty easily.

Unlike the wedding itself, which is over all too quickly, you’ll (hopefully) be wearing this ring every day for the rest of your life – so it’s important you like the way it looks and feels. But again, that doesn’t mean it has to cost $1,000 or more. Titanium, sterling silver, and other materials are less expensive, durable, and can be personalized for even deeper meaning. Check out some affordable wedding ring options here.

17. Plan a simple honeymoon, not an ostentatious one.

A huge, over-the-top honeymoon might sound fun, but it’s far, far cheaper (and often more enjoyable) to stay closer to home.

Instead of planning a big, expensive trip, focus on what matters: Unwinding after those hectic weeks leading up to your wedding, and savoring some time alone with your new spouse. An 18-hour flight across the world with multiple connections isn’t going to help in that regard.

You could even just hop in the car and spend a week or two seeing all of the local sights you’ve never had time to see until now. Whatever you do, just enjoy this time together.

Bonus idea: If you’re set on a more distant honeymoon, try paying for most of your wedding expenses with a credit card that offers great travel rewards or a sign-up bonus, which could help cover the cost of your flight (but pay off the balance before it accrues any interest).

• Related: Seven Cheap Romantic Getaways

18. Involve your closest friends and family in the preparations.

As you’re brainstorming cheap wedding ideas, you should get your closest friends and family involved with the details. Quite often, they’ll have surprisingly good ideas that can save you money and effort.

For example, they might know a vendor that would offer you a deal, or have something you could borrow for your special day. Good friends and family are always there to help, and they’ll be especially happy to contribute to such a joyful occasion — so you might as well take advantage of their generosity.

19. Try not to mention the ‘w-word’ at first when hiring a vendor.

Many florists, bakeries, photographers, and musicians mark up their services — sometimes by a lot — just for weddings. Formal gowns are often far more expensive in white. The same cover band that plays at a bar downtown on a Saturday night for $1,000 might charge $5,000 for a wedding. This is partly because of the added pressure and preparation that a wedding involves, but it’s also partly just because they can.

When shopping around, try and get straightforward quotes for the services you need — without mentioning the wedding part at first. You need a tasteful cake for 100 people. (It could be a corporate event or retirement party.) You need someone to photograph an outdoor event for about five hours. (What would they charge to take photos of a high school track meet?)

At some point, you’ll need to come clean and explain that it’s for your wedding, especially before signing a contract. But if you can get a ballpark estimate for the services you need before revealing that it’s actually for your big day, you might have better negotiating leverage when they suddenly try to apply a hefty wedding markup for the exact same service.

20. Plan, plan, plan.

When you’re trying to have a wedding on a budget, it’s important to plan ahead. List everything you can think of and walk through these items step by step.

The earlier you get started – and the more things you think about early on – the less “last-minute stress” you’ll have, and the more time you’ll have to find sales and discounts and research other good ideas.

21. Don’t stress.

Something will probably go wrong at the last minute – a little detail of some sort won’t work out. For example, our pastor almost missed our rehearsal dinner, so we barely rehearsed.

Don’t worry about it. Just assume something little is going to go wrong and avoid the urge to throw money at the problem. Most likely, no one will even notice the little issue, and quite often someone in your wedding party (or someone helping out) will come up with a pretty good solution to fix things.