EDITOR'S NOTE: This article was originally published online last week, but following review by members of the editorial board to correct minor factual errors, it has been revised and republished. IntroductionThe COVID-19 pandemic has brought about robust changes to the traditional practice of healthcare in the United States. In a time…
September 24, 2019
With late signatures, can you still bill for your medical services?
Late physician signatures pose serious issues. In the last few months, I have had questions about late signatures on documentation come in from several clients. I've been hearing about providers signing their notes a very long time after the encounter – sometimes weeks later, sometimes months, and sometimes even turning…
July 16, 2019
Roadkill as Documentation
All bad documentation is based on lies – the lies doctors (and all human beings) tell themselves. We always believe our lies, because they are how we construct a false reality that makes our bad behavior seem acceptable to ourselves. Theologians might call it original sin, humanists might call it…
April 23, 2019
The Need for Creating a Culture of Compliance
Understanding why a culture of compliance in coding and documentation is so important. Compliance is a large part of our duties in healthcare. It is especially true for coding. With so many regulations, the audit atmosphere and payment nightmares, quite simply we are a moving target. For those of us…
March 19, 2019
A CDI Revolution Unfolding
As the provision of healthcare changes, so too must clinical documentation improvement. I have always been convinced of the strong capabilities of current clinical documentation integrity (CDI) initiatives to achieve tremendous improvement in the completeness and quality of documentation and communication of patient care in the electronic health record. Today’s…
New program for live CDI education is gaining traction. Last week, I shared details about a new activity I have been doing with a client that I think is extremely beneficial, and suggested that perhaps others could implement a similar program in their own practices. I was asked to lay…
New CMS document features gems that fill risk adjustment voids for coding rules. Coders love rules. In risk adjustment coding, we live by the Official Guidelines for Coding and Reporting, the ICD-10-CM conventions for code lookup, and the AHA Coding Clinic for ICD-10-CM and ICD-10-PCS. Too often, though, we run…
April 24, 2018
Advocating for Better Physician Documentation: Do No Harm
Early documentation instruction sorely lacking Last week, during ICD10monitor’s Talk Ten Tuesdays broadcast, Larry Field, DO, treasurer of the American College of Physician Advisors (ACPE), shared the tale of a relatively new hospitalist who was disenchanted with medicine and considering a transition into physician advising after only three years of…
April 24, 2018
Holistic Approach to CDI Appears Promising
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…
CCD is when the typical and customary documentation of a condition does not line up with the available codes or the indexing. Last week, I discussed the Type 2 MI issue. This week, I will address the higher-level problem of the “coding-clinical disconnect,” which I am going to refer to…