CDI - ICD10monitor

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…
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…
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…
Last month, the American Health Information Management Association (AHIMA) released a practice brief titled “Impact of Physician Engagement on Clinical Documentation Improvement Programs.” The brief contains some extremely valid and interesting points. Genuine, consistent physician engagement is essential for any clinical documentation improvement program meant to achieve scale and long-term…
It's apparent that the traditional fee-for-service model for reimbursement cannot be sustained. New concepts have been introduced in the industry and some have "died on the vine,” others such as bundled payments are evolving, and new models have erupted, such as those outlined in the Medicare Access and Chip Reauthorization…
The addendum for new codes coming out was recently released with many notable additions and deletions. The next several articles in this series will address some of these conditions in order to help us get ready for the October 1 implementation date.One of the things I love most about getting…
Just as we’re getting our minds wrapped around the 2,398-page Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, published by the Centers for Medicare & Medicaid Services (CMS) on Oct. 14, 2016 and becoming effective Jan. 1, 2017, a new proposed rule for 2018 was published on June 20,…
Clinical documentation integrity (CDI) as a profession is quite similar in nature to running a business. Successful businesses exhibit certain operational qualities and traits that serve to ensure continued growth and prosperity, and their leaders possess a long-term vision and ability to consistently meet, exceed, and solidly predict current and…