Sharing insights on assumptive coding  When I was a physician advisor, I used to offer a diabetic Charcot joint as an example of why we must be explicit with linkage. Years ago, if a provider listed diabetes mellitus and a Charcot joint (neuropathic osteoarthropathy) as concomitant diagnoses without documenting clear…
Indiscriminate copying and pasting is the enemy of accurate, complete, concise, and relevant documentation. Does copy and paste make you as crazy as it does me?! I have been doing a lot of chart reviews lately, and the only saving grace is that this healthcare system has a mechanism to…
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…
We are hearing lots about ICD-10-CM/PCS (International Classification of Diseases, 10th revisions, Clinical Modification/Procedure Coding System) documentation needs.