CDI - ICD10monitor

The CDI is more than diagnosis capture through the query process. The Association for Clinical Documentation Improvement Specialists (ACDIS) recently released a paper titled Proactive CDI: Tackling the Problem of Physician Engagement, which featured six CDI leaders outlining their thoughts and ideas on facilitating physician engagement in CDI initiatives within…
All sepsis now is the condition formerly known as severe sepsis. EDITOR’S NOTE: Dr. Erica Remer reported this story live during the Aug. 13 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting. I’m the co-chair of the American College of Physician Advisors CDI Education Subcommittee.…
Don’t preoccupy yourself with DRGs, CCs and MCCs. I don’t think about my previous life as a practicing physician much, but I took a little trip down memory lane this morning. When I was on my pediatrics rotation in Buffalo, I had a supervising resident who had the most profound…
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…
“Let me count the ways.” EDITOR’S NOTE: Dr. Remer reported on this topic during the most recent edition of Talk Ten Tuesdays. I have been doing a project evaluating emergency department documentation, and many of the emergency providers utilize voice recognition. As such, illegibility has been replaced by unintelligibility. I…
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…
The author shares highlights from the annual conference. I am continuing my reporting on tidbits I learned at the Association of Clinical Documentation Improvement Specialists (ACDIS) annual conference in May. As I mentioned last week, I was honored to make closing remarks on the first day. I shared my grand…
The author shares highlights from the annual conference. From May 20-23, I was in Kissimmee, Fla. with many of you at the ACDIS annual conference. It was really affirming for so many of you to come up to me and express your appreciation for Talk-Ten-Tuesdays. It’s nice to know there…
Maybe it is time for physicians to stop being S.O.A.P. bubbleheads. There is no denying that poor documentation is a serious, universal problem. However, most of our documenting colleagues are in serious denial about the problem. But some of the denials flying about in the locust cloud of insurance denials…
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…