CDI - ICD10monitor

Hospital services must positively contribute to the revenue cycle and clinical documentation integrity initiatives. A recent outlook report released by Moody’s Investors Services spells continued ongoing financial challenges for non-profit hospitals next year. (Moody's Survey) The firm downgrade the sector from its current stable status to negative for 2018, attributable…
Leaving 2017 and moving into 2018, three major issues await coders—issues that could be opportunities.As we now come to the end of another year and look towards the next, what are the big issues for coding professionals? I often think about the new Official Coding & Reporting Guidelines and the…
Dieticians’ findings must find their way into the medical record to achieve proper care and coding. Diagnosing malnutrition is not diving for dollars.Malnutrition – and I am specifically talking about undernutrition today – is a common but frequently unrecognized problem that leads to difficulty healing from trauma or surgery, or…
An insider’s look at coding Alzheimer’s and its associated symptoms.EDITOR’S NOTE: The following is an edited transcript of Laurie Johnson’s recent appearance on Talk Ten Tuesdays.The late President Ronald Reagan designated November as National Alzheimer’s Disease Awareness Month in 1983 in order to help fight the dreaded condition. As Baby…
Eight key guidelines for ensuring proper coding. EDITOR’S NOTE: The following is a summary of a presentation by Margaret Skurka during the 2017 American Health Information Management Association (AHIMA) national convention in Los Angeles. Evaluation and management (E&M) documentation principles have been around a long time – since 1995, in…
Quality of clinical documentation and ICD-10 diagnosis code accuracy and specificity are essential under MACRA.My presentation at the 2017 American Health Information Management (AHIMA) convention stressed the need for understanding a basic overview of the Medicare Access and CHIP Reauthorization Act (MACRA) and its performance categories. These performance categories and…
A CDIS recently posed a question that baffled – to say the least. In my consulting practice, I often review provider documentation to identify documentation gaps and to direct my educational efforts. I also get a significant amount of information about the state of the facility’s clinical documentation integrity process.…
How CDI transforms documentation from a reimbursement perspective to a tool for patient care and support of quality-based, cost-effective, efficient healthcare.Clinical documentation improvement (CDI) programs have become deeply ingrained in most hospitals as part of a purposely directed strategy to improve financial operations.According to a survey conducted by Black Book…
CDI seen as a key solution to meeting regulatory policy changes.One thing is inevitable this time of year for all of us in healthcare: change is in the air. You either thrive amid it or hide, but even those best at hiding ultimately cannot escape. The question I often ponder…
Complexity of medical decision-making is key, but you can’t bill for something you didn’t do.This article was prompted by a Talk Ten Tuesdays listener’s question regarding his personal experience with the healthcare profession. He was evaluated in an emergency department (ED), never examined, but discovered a complete physical examination in…