Unfortunately, the quality of data is driven less by opportunity and more by incentives for those creating the data.Prior to the implementation of ICD-10, the key selling point of the new coding set was that it provided the opportunity for more detailed data about the nature of each patient’s condition.…
CTE is coded as postconcussional syndrome which is F07.81January 30th is National CTE Awareness Day according to www.stopcte.org. This organization was founded by the family of Patrick Risha who lost his battle with chronic traumatic encephalopathy (CTE) when he was in his 20’s. This young man lived in the suburbs…
From evolving your CDI department to a population-centric approach to understanding the impact of electronic medical record technology on CDI program outcomes are among six resolutions offered by the author.Happy New Year! It’s now officially 2018, and even though we are already a full quarter into the federal fiscal year,…
CDI programs are viewed by most physicians as hospital-led initiatives geared towards increasing reimbursement for the hospital.The majority of clinical documentation improvement (CDI) programs fail to effectively engage physicians as willing participants in the push to accurately capture patient care provided through clear, concise, and contextually consistent reporting. Clinical documentation…
Medical policies are based off of evidence-based medicine. Without proper documentation, however, most providers struggle to get services or procedures covered for patients.Exactly what is medical necessity? To many, it is the belief that a service or procedure is warranted or justified for a patient. Others view it as a…
December 19, 2017

Why CDI is a Game-Changer

CDI, used to clearly communicate the clinical status of a patient, comes with the increased scrutiny of third-party payers and federal oversight agencies. EDITOR’S NOTE: Stefani Daniels recently appeared on Talk-Ten-Tuesdays. The following are highlights from her segment on the broadcast.Hospitals are knee-deep in some radical changes in how and where…
Leaving 2017 and moving into 2018, three major issues await coders—issues that could be opportunities.As we now come to the end of another year and look towards the next, what are the big issues for coding professionals? I often think about the new Official Coding & Reporting Guidelines and the…
Dieticians’ findings must find their way into the medical record to achieve proper care and coding. Diagnosing malnutrition is not diving for dollars.Malnutrition – and I am specifically talking about undernutrition today – is a common but frequently unrecognized problem that leads to difficulty healing from trauma or surgery, or…
An insider’s look at coding Alzheimer’s and its associated symptoms.EDITOR’S NOTE: The following is an edited transcript of Laurie Johnson’s recent appearance on Talk Ten Tuesdays.The late President Ronald Reagan designated November as National Alzheimer’s Disease Awareness Month in 1983 in order to help fight the dreaded condition. As Baby…
Eight key guidelines for ensuring proper coding. EDITOR’S NOTE: The following is a summary of a presentation by Margaret Skurka during the 2017 American Health Information Management Association (AHIMA) national convention in Los Angeles. Evaluation and management (E&M) documentation principles have been around a long time – since 1995, in…