As the provision of healthcare changes, so too must clinical documentation improvement. I have always been convinced of the strong capabilities of current clinical documentation integrity (CDI) initiatives to achieve tremendous improvement in the completeness and quality of documentation and communication of patient care in the electronic health record. Today’s…
These conditions should be on the radar for coding and clinical documentation integrity. There has been much discussion about healthcare expenses in recent months. The Centers for Medicare & Medicaid Services (CMS) is focusing on value-based purchasing (VBP), and payors are focused on reducing costs through Hierarchical Condition Categories (HCCs)…
The goal should be a 100 percent response rate. On a recent onsite, one of the clinical documentation integrity specialists (CDISs) asked me my opinion on how assiduous a clinical documentation integrity (CDI) professional should be to get a query answered. My response may surprise some of you. I must…
Developing a team approach can positively impact coding quality and reduce coding errors. Coding professionals are faced with a myriad of challenges that can significantly impede coding quality. Such challenges include ongoing, increasing pressure to meet management productivity standards and CFO expectations to drop bills in a timely manner to…
Coders need to know when and how the cardiac arrest occurred. There are approximately 350,000-400,000 cases of cardiac arrest arising outside of the hospital setting per year, and not all of these patients make it to the emergency department. The incidence in any given hospital on any given shift is…
Noncompliant queries can be overt or subtle.The underlying hallmark of clinical documentation integrity (CDI) programs is the query process utilized to clarify documentation from a diagnosis perspective. Much emphasis is placed upon ensuring the issuing of a compliant query by the clinical documentation integrity specialists, reinforced by the American Health…
Integrity means moving from a retroactive, transactional approach to one that documentations patient care. There is much discussion and movement in the clinical documentation improvement (CDI) industry regarding using the word “integrity” in describing the discipline. In perusing the Internet for a solid definition of “integrity,” a Huffington Post article…
When considering to use the T code, simply tell the truth. Is your institution reluctant to code a T code? Are your quality professionals concerned about being penalized for any complication that crops up during the patient stay? Are they asking the clinical documentation integrity (CDI) team to contrive by…
CDI is the critical link to quality outcomes.   Any healthcare system’s overall performance relies heavily on a strong clinical documentation integrity (CDI) program, and therefore on the professionals at the heart of this discipline. From patient outcomes and mortality rates to financial reimbursements and quality score profiles, CDI programs…
New coding clinic edition offers much to review and follow.Everyone in health information management (HIM), coding, and CDI (clinical documentation improvement) is abuzz about the fourth-quarter AHA (American Hospital Association) Coding Clinic on ICD-10-CM/PCS. We just received the third-quarter issue at the end of September, which everyone is still digesting.…