EDITOR’S NOTE: The late Robert S. Gold, MD tackled the issue of sepsis even before the advent of the 1992 SIRS criteria. He made certain that healthcare professionals should be aware that capturing the true clinical picture should be first and foremost on the agenda. This is the first in…
EDITOR’S NOTE: This is the first in a two-part series examining how to manage a CDI program using Key Performance Indicator management strategies.Managing a clinical documentation improvement (CDI) program is about much more than just coordinating time-off requests, allocating budget items, coordinating meetings and trainings, facilitating the occasional audit, or…
Before I begin, I would like to take a moment and acknowledge Dr. Robert Gold, who passed away last week. Dr. Gold was a pioneer and leader in our field of clinical documentation improvement (CDI) and coding. He was first my mentor, then my colleague, and then my friend. I…
Last week at the Health Care Payment Learning and Action Network Spring Summit, there was some great information shared with representatives of the industry.For those who don’t know about the HCP LAN, they say in order to help achieve better care, smarter spending, and healthier people, the U.S. Department of…
One of the biggest lingering questions facing the healthcare industry today is this: how do we keep physicians from becoming administrators rather than clinicians?Having a quality clinical documentation improvement (CDI) program in place can grant physicians the necessary flexibility and time to dedicate to their patients while still providing an…
Complication coding is a hot topic among coding, clinical, and compliance professionals. It’s considered to be one of the more challenging aspects of coding. Physicians are hesitant to document post-operative complications, as they negatively affect their quality scores on sites like Healthgrades.com. Hospitals, however, need to be compensated for the…
This is a very exciting time to be in the field of clinical documentation improvement (CDI), with so many emerging opportunities beyond just reviewing for major complications and comorbidities (MCCs) and complications and comorbidities (CCs). CDI programs are growing into so much more than just a mechanism for reviewing documentation…
At this point, most clinical documentation improvement (CDI) programs are well-versed in the topic of malnutrition. New and old programs alike acknowledge that malnutrition is under-documented and that appropriately establishing this diagnosis for the patient can improve severity-of-illness metrics.
Recently I served as a panelist for Talk Ten Tuesdays, ICD10monitor’s weekly Internet program. The program covers a variety of topics, but ICD-10 is its primary focus.   The experience got me to thinking: we are already seeing, ICD-10 can provide us some rich data, and this directly ties to…
“Patient with transaminitis, keep watching labs.” “Patient’s liver enzymes extremely elevated, keep in ICU.” Physicians may have seen these notes before. But transaminitis and “extremely elevated liver enzymes” do not equate to shock liver or acute and subacute hepatic failure without coma.