CDI - ICD10monitor

“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 As such, illegibility has been replaced by unintelligibility.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…
Guidance and advice effective with discharges occurring on and after March 20, 2019.  For coding and CDI (clinical documentation improvement/integrity) professionals, it’s exciting to read over the American Hospital Association (AHA) Coding Clinic on ICD-10-CM/PCS. This publication is a must-have document with must-follow guidance. Although ICD10 University held a webinar regarding…
When efficiency is not truly efficient, after all. “Efficiency” may be defined in many ways, including the following, as described by dictionary.com: Able to accomplish something with the least waste of time and effort; competency in performance. An accomplishment or ability to accomplish a job with a minimum expenditure of time…
The AHIMA World Congress (AWC) team used gap analysis to report new opportunities for Al Ain Hospital in the UAE. EDITOR’S NOTE: Dr. Lo will be a guest speaker during today’s edition of Talk Ten Tuesdays, and he offered the following thoughts with ICD10monitor ahead of the appearance. I am…
The “economic burden” of prescription opioid misuse is nearly $80 million. We were discussing opioid dependence in my CDI education session last week and it spurred me to write this article. Each week we review a topic often elicited by a real-life case. Opioid misuse and addiction is a public…