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Documentation becomes meaningful when using evidence-based medicine. I see a lot of conversations ongoing about clinical documentation integrity (CDI) efforts that in my opinion, seem to reflect a less-than-productive way of gaining progress. CDI should be about documenting for evidence-based medicine, and not coding guidelines. Coding guidelines have no place…
2019 AHIMA Clinical Documentation Improvement (CDI) Summit Summary At the American Health Information Management Association’s (AHIMA’s) recent Clinical Documentation Improvement (CDI) Summit, CDI industry experts shared insights on the most pressing issues affecting the CDI industry. Real-world examples and best practices on compliance, documentation across the healthcare continuum, clinical validation,…
Four areas where HIM professionals impact collections. I met with a coding manager recently who shared that her annual pay increase would be partially based on collections. Of course, we both looked at each other and said “why?!” But then I reflected on it and said, “why not?”  We know…
An effective query process aids the hospital’s compliance with billing/coding rules. According to the American Health Information Management Association (AHIMA), Centers for Medicare & Medicaid Services (CMS), AAPC, the American Medical Association (AMA), and many other authoritative sources, a query can be a powerful communication tool used to clarify documentation in…
Cliff notes for the FY20 ICD-10-CM Guidelines for Coding and Reporting. EDITOR’S NOTE: Senior healthcare consultant Laurie Johnson reported this story live during Aug. 13 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting. Last week, I announced that the 2020 ICD-10-CM guidelines were finally released…
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.…
Some proposed IRF provisions were not finalized. On July 31, 2019, the Centers for Medicare & Medicaid Services (CMS) issued the final rule for the inpatient rehabilitation facility prospective payment system for the fiscal year 2020. The proposed rule is on display for review at this link:  IRF FY 2020…
Clinical documentation improvement (CDI) failed to achieve improvement. EDITOR’S NOTE: Hahnemann University Hospital is a 427-bed academic medical center affiliated with Drexel University located in Philadelphia that primarily serves the healthcare needs of Medicare and Medicaid patients. The hospital recently filed bankruptcy due to long-standing financial challenges that became unsustainable. Hahnemann…