CDI - ICD10monitor

It is highly recommended to self-audit first, internally, with qualified staff. EDITOR’S NOTE: This is the first in a four-part series on the importance of passing or failing an audit and avoiding being a red-flag to payers. One of the services I offer, aside from coding and billing education, is…
Type 2 MI is not a coding construct.  I received some correspondence regarding my Type 2 myocardial infarction article last week which prompted me to ponder the coding-clinical disconnect. Let us address the Type 2 MI concerns this week, and next week, I will tackle the broader picture. Historically, the…
Coders are encouraged to learn more about the clinical conditions associated with the patient encounters they are coding. As coders, we often struggle with assigning the correct codes. There are many gray areas in the guidelines and instructional notes, and sometimes even conflicting information can be found. This leads to…
Moving beyond CDI to optimize reimbursement requires returning to an optimal and sustainable level of achievable excellence.  A well-guided, thought-out, directed mission is paramount to driving and ensuring success in any professional role – and this particularly holds true for the profession of clinical documentation improvement (CDI). In my travels…
Recently I reviewed a case that triggered an exposition. As a clinician, I am always trying to wrap my head around a coding-clinical disconnect in the ICD-10-CM Official Coding and Reporting Guidelines regarding poisoning versus adverse effects. All medications have side effects; a clinician considers the cost-benefit ratio of each…
In this article, the author examines the implications for the capture of Hierarchical Condition Codes (HCCs) in the inpatient setting.By now, most clinical documentation improvement (CDI) programs have an appreciation for the use of cases reflecting how Hierarchical Condition Codes (HCCs) impact upon quality and reimbursement. For those who do…
Coding leadership routinely benefits from learning team members' strengths and weaknesses and adjusting plans to match. I began working with Novant Health in 2011, when I used the phrase “best of the best” for my team. This was our department’s vision for our future, and it is a standard we…
The new classification is designed as a database and has up to 13 dimensions. The World Health Organization (WHO) will be releasing the 11th Revision to the International Classification of Diseases, or ICD-11, this May. The WHO and many of its 194-member countries have been working on this since 2007.…
There is a definite need for outpatient CDI programs – provided that hospital administration takes the right approach to its development and implementation. Interest in outpatient clinical documentation integrity (CDI) programs is multiplying as more and more hospital services are moving to the outpatient setting and healthcare reimbursement models are…
Official guidance on ICD-10-CM coding raises questions regarding how to document cardiac care. The first step in choosing the proper ICD-10-CM code is reading the medical documentation to identify the diagnosis the provider has documented and confirmed. If there is no confirmed diagnosis, look for the sign or symptom that…