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By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor For cardiology, the focus of ICD-10 is generally on increased specificity and documenting the downstream effects of the patient’s condition. Acute myocardial infarction, or what is more commonly known as AMI, had a definition change when the nation’s healthcare system…
By Angie Comfort, RHIA, CDIP, CCS, CCS-P for For the Record In October 2017, the Department of Health and Human Services (HHS) declared a public health emergency to focus on the opioid crisis. Analyzing data from 2000 to 2015, HHS estimated that 91 Americans had died of opioid overdoses each day, and the numbers have…
KLAS Research is a healthcare information technology data and insights company providing the industry with accurate, honest and impartial research on the software and services used by providers and payers worldwide. Every year, KLAS collects evaluations from healthcare providers to rank vendors across several categories. This year, Dolbey is honored to announce that KLAS has…
Three questions to consider when evaluating a clinical documentation improvement program. By Lisa A. Eramo, MA for For the Record Review the record. Query the physician. Obtain the diagnosis. Repeat. Does this clinical documentation improvement (CDI) workflow sound familiar? Productivity is the hallmark of a good program. Or is it? On the surface, CDI specialists…
For HIM and CDI professionals, 2018 looks to offer a gift of the tremendous opportunity for success. By Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS for ICD10 Monitor For movie buffs, the film Darkest Hour offers a tremendous view into the early days of World War II, when the fate of Western Europe hangs on…
By Angie Dibble, RHIT for For the Record Remember when we thought of medical charts as inanimate objects, safely tucked away on a dusty shelf in a paper mill known as “Medical Records”? In my prior life, the one I innocently enjoyed before working in health information, I believed all medical charts were somehow pure…
By Angie Dibble, RHIT for For The Record Sepsis, encephalopathy, malnutrition, and acute renal failure are examples of diagnoses that often prove vexing for coders and clinical documentation improvement (CDI) specialists. What if the sepsis diagnosis is based on “technically meets sepsis criteria” because a patient with a urinary tract infection has an elevated white blood…
As health systems work to get the most from their physicians’ EHR charting, experts say it’s important to focus on the right metrics while working toward greater buy-in from doctors. By Mike Miliard for Healthcare IT News Hospitals and health systems trying to survive and thrive under value-based reimbursement realize that optimal clinical documentation is…
By Selena Chavis for For the Record Clinical documentation improvement (CDI) processes have made significant inroads in recent years. Now a mainstream strategy within any forward-looking hospital, CDI teams are critical players in the greater quality management picture as it relates to successfully positioning for value-based care. Not all CDI workflows and processes are created…
Article by Marina Kravtsova. This article was originally published on the Journal of AHIMA website on Sep 29, 2017 and is republished here with permission. Over the past nine months, the clinical documentation improvement (CDI) team that I represent has been recruited to perform so-called second level reviews. All cases presented to the CDI team for second level review thus…