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…

EDITOR’S NOTE: The following a part of a series on outpatient clinical documentation integrity (CDI). Part IV was published on May 16, 2017 in the ICD10monitor e-News.The medical record serves primarily as a physician’s communication tool for patients and all associated healthcare stakeholders. The effectiveness and completeness of the documentation…

EDITOR’S NOTE: The following is part one in a three-part series on outpatient clinical documentation integrity.There is a great push within the healthcare industry to move clinical documentation integrity (CDI) into the outpatient arena. People refer to this as “outpatient CDI,” but I think this is a misnomer. If you…

Las Vegas is best known for its casinos, crowds, and Celine Dion. But now the city can also be recognized for coding and clinical documentation improvement (CDI). Why?The American Association of Professional Coders (AAPC) and HCPro’s Association of Clinical Documentation Improvement Specialists (ACDIS) both convened in Las Vegas during the…

EDITOR’S NOTE: The following is part of a series on outpatient clinical documentation integrity (CDI). Part III was published on May 9, 2017 in the ICD10monitor eNews.Outpatient CDI specialists must first and foremost exhibit the mindset and display characteristics of a businessperson. This individual should be capable of identifying, developing,…

Recently, Dr. Joseph Cristiano did a Talk Ten Tuesdays DocTalk segment on his experience educating residents on clinical documentation at Wake Forest University. We received a follow-up question from Suzanne, so I am focusing this article on more details about resident training. During my stint as physician advisor (PA) at…

EDITOR’S NOTE: The following a part of a series on outpatient clinical documentation integrity (CDI). Part II was published on April 25, 2017 in the ICD10monitor eNews.Critical to the successful rollout of an outpatient clinical documentation improvement (CDI) program is the selection and hiring of employees to staff the program.…

EDITOR’S NOTE: The following a part of a series on outpatient clinical documentation integrity (CDI). Part I was published on April 11, 2017 in the ICD10monitor eNews.The first article of this series provided an overview, identifying and singling out key shortcomings and pitfalls of current programs. This article will focus…

In the April 22 run-up to Earth Day, Talk Ten Tuesdays recognizes the link between global warning and the physical and mental health of Americans—particularly healthcare professionals. Reporting on this link will be nationally prominent psychiatrist H. Steven Moffic, MD. Dr. Moffic has written extensively about physician burnout and in…