Creating a new vision for CDI. There has certainly been much discussion in the revenue cycle community regarding the “I” in CDI, with the idea of changing clinical documentation “improvement” to “clinical documentation integrity.” Rather than centering on “improvement” versus “integrity,” though, fundamentally, the discussion should focus upon defining what…
Guidance and advice effective with discharges occurring on and after March 20, 2019.  For coding and CDI (clinical documentation improvement/integrity) professionals, it’s exciting to read over the American Hospital Association (AHA) Coding Clinic on ICD-10-CM/PCS. This publication is a must-have document with must-follow guidance. Although ICD10 University held a webinar regarding…
When efficiency is not truly efficient, after all. “Efficiency” may be defined in many ways, including the following, as described by dictionary.com: Able to accomplish something with the least waste of time and effort; competency in performance. An accomplishment or ability to accomplish a job with a minimum expenditure of time…
The AHIMA World Congress (AWC) team used gap analysis to report new opportunities for Al Ain Hospital in the UAE. EDITOR’S NOTE: Dr. Lo will be a guest speaker during today’s edition of Talk Ten Tuesdays, and he offered the following thoughts with ICD10monitor ahead of the appearance. I am…
The “economic burden” of prescription opioid misuse is nearly $80 million. We were discussing opioid dependence in my CDI education session last week and it spurred me to write this article. Each week we review a topic often elicited by a real-life case. Opioid misuse and addiction is a public…
Semantics aside, clinicians must recognize sepsis and treat it aggressively, to save lives. A few weeks ago, I had a fascinating discussion with Tim Brundage, a physician friend, and fellow clinical documentation improvement (CDI) expert, my co-chair on the American College of Physician Advisors (ACPA) CDI committee,  and I’d like…
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…