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From the ACDIS CDI Blog Because every chart is coded before being sent to payers, it’s important that CDI specialists have a working knowledge of code sets and coding rules. The inpatient prospective payment system (IPPS) final ruling, traditionally updated annually, has been changed to update twice a year on April 1 and October 1 beginning…
From For the Record AHIMA and the Association of Clinical Documentation Integrity Specialists (ACDIS) released a new white paper that examines how rapid advancement in health care technology is driving changes to the practice of clinical documentation integrity (CDI). CDI is critical to the usability of medical data and ongoing efforts to improve patient care. New technologies, such as artificial…
By Karen Newhouser, RN, BSN, CCDS, CCDS-O, CCS, CDIP, CCM from the ACDIS CDI Blog As the CDI and coding professions continue to evolve, query guidance methods have changed along with them. The first industry standard brief, “Developing a Physician Query Process,” published by AHIMA in 2001, set the foundation for the compliant query practice.…
For ACDIS CDI Blog Q: I’ve been told that if there are clinical indicators to support that chronic kidney disease (CKD) is the etiology of a patient’s hypertension, a code from category I15 would be assigned. Code I12 is for hypertensive CKD, isn’t it? So why do we have to use I15 codes instead? What’s…
By Jonathan Rubenstein, MD, Mark Painter for Urology Times New and updated codes encompass balloon continence devices, hypospadias Current Procedure Terminology (CPT) codes are continuously being updated. New and updated Category I and III codes will become active on January 1, 2022. In addition, some other Category III codes may be released on July 1 of…
By Kelly Sutton, RN, BSN, MHL, CCDS for ACDIS CDI Blog The transition into CDI from other avenues can be filled with overwhelming thoughts and emotions. In my experience as division educator, almost every CDI specialist will, at some point, have doubts about their career change. In the CDI specialist role, the relationships with physicians…
By Marlene Goodwin-Esola, MSN, CV-BC, NE-BC for ACDIS CDI Blog When I first entered the CDI field, I received feedback from someone who left this specialty expressing that her reason for leaving was that CDI was “too sad.” Her rationale was that as a CDI specialist, you might be reviewing a chart of a patient…
From For the Record Magazine Innovative work to meet the urgent public health need for streamlined reporting and tracking of COVID-19 vaccinations is presented in the release of the 2022 set published by the American Medical Association (AMA). The annual update to the CPT code set incorporates a series of 15 vaccine-specific codes that are…
By Howard Rodenberg, MD, MPH, CCDS for ACDIS CDI Blog In one of my recent efforts for the ACDIS Blog, I mentioned that there were times when it might be better not to query. I’ve also mentioned that before one sends a query, one needs to take into account the entire context of the patient encounter. I’d like…
ACDIS Journal Excerpt from The ACDIS CDI Blog No matter the level of training and preparation you put into implementing a new technology, you’ll likely still encounter some struggles along the adoption journey. Inevitably, regardless of the project, there will always be a few troublesome providers, according to Vaughn Matacale, MD, CCDS, director of the CDI advisor…