The accurate diagnosis of sepsis is not for DRG assignment. There has been quite a bit of controversy stirred up by UnitedHealthcare (UHC) and its approach to sepsis, and since I am wrapping up a fascinating targeted sepsis project, I want to share what I have learned with you. I…
Integrity means moving from a retroactive, transactional approach to one that documentations patient care. There is much discussion and movement in the clinical documentation improvement (CDI) industry regarding using the word “integrity” in describing the discipline. In perusing the Internet for a solid definition of “integrity,” a Huffington Post article…
Address documentation and coding issues up front, rather than correct them later. Coders have had many challenges throughout the years.  When I started in the industry, we did not submit claims electronically; they were submitted on paper and we used an IBM Selectric Typewriter to complete what was then the…
Nonaccidental trauma (NAT) should code to “child abuse, suspected or confirmed.”The challenges of coding “child abuse, suspected or confirmed” is becoming a source of increased interest for me. When ICD-10 rolled out, as among the changes was a coding guideline that included a code for “child abuse” (and any time…
Strive to achieve coding compliance that really works. I’m often asked about how one would or should strive for coding compliance and make it happen. The first thing I do is to identify and acknowledge the risks or potential risks that occur. We all know that there are risks across…
CDI, when properly performed, supports the ancient physician oath, “First, do no harm.”  Clinical Documentation Improvement Specialists(CDISs) play a vital role in the overall scheme of healthcare delivery through affecting measurable meaningful improvement in the quality, completeness, and accuracy in the telling of the patient story. The major beneficiaries of…
Each patient’s story should be told in the official record. The clinical documentation integrity (CDI) profession has only scratched the surface of instilling positive change in patterns of physician documentation and communication of patient care. There exists a myriad of opportunities for CDI specialists to capitalize upon and truly improve…
If physician training and education on clinical documentation is not done correctly, you might as well not do it at all It is common knowledge that the reason clinical documentation integrity (CDI) programs exist is to bridge the gap between the language physicians speak and what can be accurately captured…
Back in November, I wrote about clinical documentation improvement (CDI) in the medical practice and the importance of this critical step in adopting ICD-10. It will not only improve diagnosis coding, but also compliance for procedures and services reported by the practitioner.
EDITOR’S NOTE: This article marks the beginning of a series of articles on clinical documentation improvement by clinical service. Changes associated with switching from ICD-9-CM to ICD-10-CM/PCS typically are reviewed in total and discussed service by service. When reviewing by individual services, the variances between the two classification systems will…