Expanding clinical conversations to involve all players can only benefit the entire organization. EDITOR’S NOTE: This article is based upon Dr. Erica Remer’s remarks during a recent live Talk Ten Tuesdays Internet broadcast. A while back, I told readers about a fun activity I do with one of my clients.…
The actual go-live of ICD-10-CM/PCS was generally smooth, with no major problems.  For health information management (HIM) coding and clinical documentation improvement/integrity (CDI) professionals, the use of and adherence to the ICD-10-CM/PCS Official Guidelines for Coding and Reporting is a must. In addition, the American Hospital Association (AHA) ICD-10-CM/PCS Coding…
The risks of using the Internet to self-diagnose and code. A majority of us turn to the Internet for health-related information. According to the Pew Research Center, in 2014, a total of 87 percent of American adults had access to the Internet, and in 2012, a total of 72 percent…
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 As such, illegibility has been replaced by unintelligibility.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…