EDITOR’S NOTE: This is the first in a two-part series on the coding and documenting of social determinants of health (SdoH). It comes on the heels of the aftermath of Hurricanes Harvey and Irma and their impact on victims and survivors in the flood-ravaged cities of Texas and Florida. Hurricanes…
Now it’s just a little less than three weeks until the beginning of October and when the fiscal year (FY) 2018 changes for ICD-10-CM take effect.  Here is a summary of the new changes for ICD-10-CM: 360 new code additions 142 deletions 250+ revisions The Centers for Medicare and Medicaid…
Last week Tracy Boldt contacted me to ask a question about outpatient clinical documentation integrity (CDI), and we are lucky to have her on the Talk-Ten-Tuesdays broadcast today, detailing Essentia Health’s successful outpatient CDI program. She also mentioned that she had been awaiting the third installment of my three-part series…
A recent conversation with a fellow clinical documentation integrity (CDI) specialist about the role of the profession as it pertains to enhancing and affecting positive change in communication of patient care by transitioning to a more holistic approach really struck a chord in me – and it made me question…
EDITOR’S NOTE: The following is the third and final installment in a three-part series by Dr. Remer on outpatient clinical documentation integrity.In the first two parts of this series, we talked about risk adjustment in general, the shift to population health management, and how quality metrics and reimbursement are linked…
Approximately every five years, the American College of Cardiology, the American Heart Association, the European Society of Cardiology, and the World Heart Federation convene workgroups to try to standardize the definition of myocardial infarction (MI) for both documentation and research purposes.  The last iteration in 2012 produced five different classifications.The…
Last month, the American Health Information Management Association (AHIMA) released a practice brief titled “Impact of Physician Engagement on Clinical Documentation Improvement Programs.” The brief contains some extremely valid and interesting points. Genuine, consistent physician engagement is essential for any clinical documentation improvement program meant to achieve scale and long-term…
It's apparent that the traditional fee-for-service model for reimbursement cannot be sustained. New concepts have been introduced in the industry and some have "died on the vine,” others such as bundled payments are evolving, and new models have erupted, such as those outlined in the Medicare Access and Chip Reauthorization…
The addendum for new codes coming out was recently released with many notable additions and deletions. The next several articles in this series will address some of these conditions in order to help us get ready for the October 1 implementation date.One of the things I love most about getting…
Just as we’re getting our minds wrapped around the 2,398-page Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, published by the Centers for Medicare & Medicaid Services (CMS) on Oct. 14, 2016 and becoming effective Jan. 1, 2017, a new proposed rule for 2018 was published on June 20,…