The goal should be a 100 percent response rate. On a recent onsite, one of the clinical documentation integrity specialists (CDISs) asked me my opinion on how assiduous a clinical documentation integrity (CDI) professional should be to get a query answered. My response may surprise some of you. I must…
Clinical validation denials continue to climb. When payers issue clinical validation denials, they challenge diagnoses documented in the chart by the providers caring for the patient. Sometimes, it’s not simply the validity of diagnoses in question, but whether coding rules were violated.  This being the case, assessment and subsequent potential…
New initiative is detailed in the OIG work plan. As many of you are aware, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released a key addition to its work plan announcing an initiative to investigate and validate their concern of hospitals gaming…
To link, or not to link: that is the question for physician documentation Since the adoption of the ICD-10 code set, clinical documentation integrity specialists (CDISs) have experienced an ongoing dilemma of capturing complication codes with regard to adverse drug events versus ‘known’ or ‘inherent’ side effects. At our organization,…
CDI is the critical link to quality outcomes.   Any healthcare system’s overall performance relies heavily on a strong clinical documentation integrity (CDI) program, and therefore on the professionals at the heart of this discipline. From patient outcomes and mortality rates to financial reimbursements and quality score profiles, CDI programs…
A CDIS recently posed a question that baffled – to say the least. In my consulting practice, I often review provider documentation to identify documentation gaps and to direct my educational efforts. I also get a significant amount of information about the state of the facility’s clinical documentation integrity process.…
Complexity of medical decision-making is key, but you can’t bill for something you didn’t do.This article was prompted by a Talk Ten Tuesdays listener’s question regarding his personal experience with the healthcare profession. He was evaluated in an emergency department (ED), never examined, but discovered a complete physical examination in…
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…
Clinical documentation integrity (CDI) as a profession is quite similar in nature to running a business. Successful businesses exhibit certain operational qualities and traits that serve to ensure continued growth and prosperity, and their leaders possess a long-term vision and ability to consistently meet, exceed, and solidly predict current and…
EDITOR’S NOTE: The following is part one in a three-part series on outpatient clinical documentation integrity.There is a great push within the healthcare industry to move clinical documentation integrity (CDI) into the outpatient arena. People refer to this as “outpatient CDI,” but I think this is a misnomer. If you…
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