Now it’s just a little less than three weeks until the beginning of October and when the fiscal year (FY) 2018 changes for ICD-10-CM take effect.  Here is a summary of the new changes for ICD-10-CM: 360 new code additions 142 deletions 250+ revisions The Centers for Medicare and Medicaid…
Today my thoughts go out to the people of Texas, especially the first responders and caregivers and all of those being impacted by Hurricane Harvey. Harvey made landfall in Texas on Friday night as the strongest hurricane to hit the U.S. in more than a decade, and because it has…
This is the year of many Centers for Medicare & Medicaid Services (CMS) regulatory requirement changes. This includes the Merit-Based Incentive Program (MIPS), the next steps toward mandatory Authorized Use Criteria (AUC) implementation for advanced imaging, defining more explicitly what is and what is not “quality” care, etc.  It is…
Last week Tracy Boldt contacted me to ask a question about outpatient clinical documentation integrity (CDI), and we are lucky to have her on the Talk-Ten-Tuesdays broadcast today, detailing Essentia Health’s successful outpatient CDI program. She also mentioned that she had been awaiting the third installment of my three-part series…
A recent conversation with a fellow clinical documentation integrity (CDI) specialist about the role of the profession as it pertains to enhancing and affecting positive change in communication of patient care by transitioning to a more holistic approach really struck a chord in me – and it made me question…
For my last article, I wrote about unexplained clinical variation as it pertains to surgical procedures. Today I continue exploring this theme.For men with low-risk prostate cancer, randomized controlled trials have found that active treatment such as radiation or prostatectomy does not improve mortality rates as compared to an initial…
Upon seeing signature attestations of medical scribes on client documents, I became curious as to their duties and training. I was interested in exploring a way in which they may contribute to the goal of clinical documentation improvement (CDI) programs. Since scribes can be employed in any healthcare environment or…
It’s that magical time of year for parents everywhere: back-to-school time. With a return to school comes a flurry of activity and planning and, in addition to obtaining school supplies and new clothes, parents must begin figuring out what their kids are going to eat for lunch. Whether that lunch…
EDITOR’S NOTE: The following is the third and final installment in a three-part series by Dr. Remer on outpatient clinical documentation integrity.In the first two parts of this series, we talked about risk adjustment in general, the shift to population health management, and how quality metrics and reimbursement are linked…
Approximately every five years, the American College of Cardiology, the American Heart Association, the European Society of Cardiology, and the World Heart Federation convene workgroups to try to standardize the definition of myocardial infarction (MI) for both documentation and research purposes.  The last iteration in 2012 produced five different classifications.The…