CDI - ICD10monitor

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…
Amid the chaos of the ED, order is needed.EDITOR’S NOTE: This is the final installment in a two-part series on clinical documentation integrity (CDI) in the emergency department (ED).It is my opinion that investing CDI resources into the neglected stepchild that is the hospital system ED is a worthwhile endeavor.…
AHIMA conference programs include subjects designed to improve one’s proficiency in the areas of coding, documentation and compliance.The American Health Information Management Association (AHIMA), holding its annual convention and exhibit in Los Angeles this week, has as a theme, “Inspire, Innovate and Lead.” It  is a joy to attend as…
The mass shooting in Las Vegas has prompted renewed attention on emergency medicine and trauma care and especially on the clinical documentation of care in this setting. I practiced emergency medicine (EM) for twenty-five years before I transitioned to being a physician advisor. My expertise had been in the professional…
A comprehensive look at how clinical documentation improvement and the actual practice of medicine overlap.There are a multitude of business and ancillary healthcare processes that serve to support the practice of medicine. That practice centers on direct patient care, facilitated and dependent upon specific synergistic processes that contribute to cost-effective,…
Hospital CDI managers always look for process improvement. Essentia Health’s outpatient CDI operation provides a practical case study. EDITOR’S NOTE: This the final installment in a two-part series on the clinical documentation integrity department at Essentia Health, a health system that serves Minnesota, Wisconsin, North Dakota, and Idaho.Becker’s Hospital Review…
EDITOR’S NOTE: This is the second installment in a two-part series on the coding and documenting of social determinants of health (SDoH). It comes on the heels of the aftermath of Hurricanes Harvey and Irma and their impact on victims and survivors in the flood-ravaged states of Texas and Florida.The…
EDITOR’S NOTE: This the first in a two-part series on the clinical documentation integrity department at Essentia Health, a health system that serves Minnesota, Wisconsin, North Dakota, and Idaho.Previously, Essentia Health’s clinical documentation improvement (CDI) department consisted of three segregated, separated, regional teams. Employees had minimal interaction with each other.…
EDITOR’S NOTE: This is the first in a two-part series on the coding and documenting of social determinants of health (SdoH). It comes on the heels of the aftermath of Hurricanes Harvey and Irma and their impact on victims and survivors in the flood-ravaged cities of Texas and Florida. Hurricanes…
Now it’s just a little less than three weeks until the beginning of October and when the fiscal year (FY) 2018 changes for ICD-10-CM take effect.  Here is a summary of the new changes for ICD-10-CM: 360 new code additions 142 deletions 250+ revisions The Centers for Medicare and Medicaid…