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.…
New program for live CDI education is gaining traction. Last week, I shared details about a new activity I have been doing with a client that I think is extremely beneficial, and suggested that perhaps others could implement a similar program in their own practices. I was asked to lay…
CDI can drive down adversarial determinations of medical necessity and costly denials.  In my article published last week, titled Moving in the Right Direction in Getting to the Root Cause of Clinical Documentation Improvement (CDI), I outlined that CDI plays a major role indeed in the context of overall healthcare…
Ongoing ethical issues persist requiring leadership guidance daily We live and work in times that are very challenging, and ever-changing to say the least. We also live and work in times in which our ethics seem to be challenged on a regular basis.  One just has to open any newspaper,…
The clinical query process is a small yet important part of any CDI initiative.By now I am confident that most in the clinical documentation improvement (CDI) industry are familiar with the lawsuit brought by data analytics firm Integra against Providence Health to recover $188 million for alleged upcoding perpetuated by…
Recent FCA activity focuses on coding compliance issues Recently in healthcare news were articles about two legal actions that cause one to reflect on the need for a strong (or stronger) coding and clinical documentation improvement (CDI) compliance programs.  The first legal action cited the False Claims Act (FCA) and…