Moving beyond CDI to optimize reimbursement requires returning to an optimal and sustainable level of achievable excellence.  A well-guided, thought-out, directed mission is paramount to driving and ensuring success in any professional role – and this particularly holds true for the profession of clinical documentation improvement (CDI). In my travels…
Recently I reviewed a case that triggered an exposition. As a clinician, I am always trying to wrap my head around a coding-clinical disconnect in the ICD-10-CM Official Coding and Reporting Guidelines regarding poisoning versus adverse effects. All medications have side effects; a clinician considers the cost-benefit ratio of each…
In this article, the author examines the implications for the capture of Hierarchical Condition Codes (HCCs) in the inpatient setting.By now, most clinical documentation improvement (CDI) programs have an appreciation for the use of cases reflecting how Hierarchical Condition Codes (HCCs) impact upon quality and reimbursement. For those who do…
Coding leadership routinely benefits from learning team members' strengths and weaknesses and adjusting plans to match. I began working with Novant Health in 2011, when I used the phrase “best of the best” for my team. This was our department’s vision for our future, and it is a standard we…
The new classification is designed as a database and has up to 13 dimensions. The World Health Organization (WHO) will be releasing the 11th Revision to the International Classification of Diseases, or ICD-11, this May. The WHO and many of its 194-member countries have been working on this since 2007.…
There is a definite need for outpatient CDI programs – provided that hospital administration takes the right approach to its development and implementation. Interest in outpatient clinical documentation integrity (CDI) programs is multiplying as more and more hospital services are moving to the outpatient setting and healthcare reimbursement models are…
Official guidance on ICD-10-CM coding raises questions regarding how to document cardiac care. The first step in choosing the proper ICD-10-CM code is reading the medical documentation to identify the diagnosis the provider has documented and confirmed. If there is no confirmed diagnosis, look for the sign or symptom that…
There are now five types of myocardial infarction (MI) code categories, and the author describes these new options and how they will impact reimbursement. For cardiology, the focus of ICD-10 is generally on increased specificity and documenting the downstream effects of the patient’s condition. Acute myocardial infarction, or what is more…
Coding the flu consists of the signs and symptoms of flu, the vaccination, and coding the actual disease and its complications This winter has been a long one for those healthcare workers who have been busy treating flu patients and trying to prevent the flu. On Feb. 7, 2018, the…
If physician training and education on clinical documentation is not done correctly, you might as well not do it at all It is common knowledge that the reason clinical documentation integrity (CDI) programs exist is to bridge the gap between the language physicians speak and what can be accurately captured…