Expanding clinical conversations to involve all players can only benefit the entire organization. EDITOR’S NOTE: This article is based upon Dr. Erica Remer’s remarks during a recent live Talk Ten Tuesdays Internet broadcast. A while back, I told readers about a fun activity I do with one of my clients.…
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…
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…
Applied correctly and consistently, these can solve the problem of missing query opportunities. With each passing year, it seems that clinical documentation improvement (CDI) branches out into new territory. In addition to performing everyday CDI tasks, it is now becoming more important than ever for CDI specialists (CDISs) to understand…
Creating a new vision for CDI. There has certainly been much discussion in the revenue cycle community regarding the “I” in CDI, with the idea of changing clinical documentation “improvement” to “clinical documentation integrity.” Rather than centering on “improvement” versus “integrity,” though, fundamentally, the discussion should focus upon defining what…
Prime Healthcare lawsuit reveals a huge risk for unethical practice. A few weeks ago, Dr. Ronald Hirsch brought to my attention (as is his custom) a False Claims Act complaint and settlement involving Prime Healthcare Services, a for-profit healthcare system. By way of background, last August, the U.S. Department of…
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…
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…
The aim of documentation is to tell the true story. Last year, I wrote a two-part series on clinical documentation integrity, specifically focusing on the emergency department (CDI in ED Part I; CDI in ED Part II). Today I will focus on how ED documentation supports medical necessity of investigative…
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…
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