CDISs urged to be prepared for changes. There is much to do on listserves and various conversations with colleagues to be had regarding the Centers for Medicare & Medicaid Services (CMS) Inpatient Prospective Payment System (IPPS) proposed rule for the 2020 fiscal year, wherein Medicare has outlined sweeping changes to…
The code assignment is not based on clinical criteria used by the provider to establish the diagnosis. Referring to the contentious ICD-10-CM Guideline I.A.19, which indicates that assignment of a diagnosis code is based on the provider’s diagnostic statement that a condition exists, Erica Remer, MD said during Tuesday’s Talk-Ten-Tuesdays…
The query process is no substitute for education and training.The hallmark of any true clinical documentation integrity (CDI) program consists of medical record chart review by clinical documentation integrity specialists (CDISs) with a goal of identifying gaps in diagnosis specificity as well as addressing other deficiencies requiring clinical clarification. Some…