“Let me count the ways.” EDITOR’S NOTE: Dr. Remer reported on this topic during the most recent edition of Talk Ten Tuesdays. I have been doing a project evaluating emergency department documentation, and many of the emergency providers utilize voice recognition. As such, illegibility has been replaced by unintelligibility. I…
All bad documentation is based on lies – the lies doctors (and all human beings) tell themselves. We always believe our lies, because they are how we construct a false reality that makes our bad behavior seem acceptable to ourselves. Theologians might call it original sin, humanists might call it…
Maybe it is time for physicians to stop being S.O.A.P. bubbleheads. There is no denying that poor documentation is a serious, universal problem. However, most of our documenting colleagues are in serious denial about the problem. But some of the denials flying about in the locust cloud of insurance denials…
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…