The CDI is more than diagnosis capture through the query process. The Association for Clinical Documentation Improvement Specialists (ACDIS) recently released a paper titled Proactive CDI: Tackling the Problem of Physician Engagement, which featured six CDI leaders outlining their thoughts and ideas on facilitating physician engagement in CDI initiatives within…
All sepsis now is the condition formerly known as severe sepsis. EDITOR’S NOTE: Dr. Erica Remer reported this story live during the Aug. 13 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting. I’m the co-chair of the American College of Physician Advisors CDI Education Subcommittee.…
Don’t preoccupy yourself with DRGs, CCs and MCCs. I don’t think about my previous life as a practicing physician much, but I took a little trip down memory lane this morning. When I was on my pediatrics rotation in Buffalo, I had a supervising resident who had the most profound…
“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 As such, illegibility has been replaced by unintelligibility.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…