CDI - ICD10monitor

Expanding clinical conversations to involve all players can only benefit the entire organization. EDITOR’S NOTE: This article is based upon Dr. Erica Remer’s remarks during a recent live Talk Ten Tuesdays Internet broadcast. A while back, I told readers about a fun activity I do with one of my clients.…
The actual go-live of ICD-10-CM/PCS was generally smooth, with no major problems.  For health information management (HIM) coding and clinical documentation improvement/integrity (CDI) professionals, the use of and adherence to the ICD-10-CM/PCS Official Guidelines for Coding and Reporting is a must. In addition, the American Hospital Association (AHA) ICD-10-CM/PCS Coding…
The risks of using the Internet to self-diagnose and code. A majority of us turn to the Internet for health-related information. According to the Pew Research Center, in 2014, a total of 87 percent of American adults had access to the Internet, and in 2012, a total of 72 percent…
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…