Computer Assisted Coding

In Outpatient CDI, Timing is Everything

Article by Susan Richards Morgan, CCS, CPHQ, CPC, CDEO, CRC, CPMA, CEMC, CPC-I. This article was originally published on the A Journal of AHIMA Blog on April 25, 2018 and is republished here with permission. Currently, most clinical documentation improvement (CDI) programs have been developed inside hospitals with an inpatient focus. Medicare generally expects an inpatient admission to need two…

Read MoreIn Outpatient CDI, Timing is Everything

Auditing Issues Uncovered in Physician Documentation: Part I

By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor Physician documentation issues during an audit go beyond CDI. EDITOR’S NOTE: This is the first in a four-part series that examines physician documentation issues as seen by an auditor. One of the services I offer, aside from coding…

Read MoreAuditing Issues Uncovered in Physician Documentation: Part I

Proper Documentation is Critical to Our Modern Healthcare System

Article by Allen Frady, RN, BSN, CCS, CCDS, CRC. This article was originally published on the Journal of AHIMA on March 29, 2018 and is republished here with permission. Is documentation improvement and proper use of ICD-10-CM critical to the nation’s healthcare debate? I say definitively yes, in every way. The bulk of the information coming from…

Read MoreProper Documentation is Critical to Our Modern Healthcare System

EHR usability issues may contribute to patient harm, JAMA study shows

By Jeff Lagasse for Healthcare Finance  The usability of electronic health records may be associated with some safety events in which patients were possibly harmed, according to a new study published in the Journal of the American Medical Association. And while the authors did not make any specific financial revelations, clinical quality has increasingly been tied…

Read MoreEHR usability issues may contribute to patient harm, JAMA study shows

Can Texting Get a Healthcare Provider in Trouble?

Article by Ron Hedges. This article was originally published on the Journal of AHIMA  on March 27, 2018 and is republished here with permission. Can texting get a healthcare provider in trouble? The answer to that question, like many other legal ones, is “it depends.” A recent decision, Latner v. Mt. Sinai Health System, Inc., No. 17-99-cv (2d Cir.…

Read MoreCan Texting Get a Healthcare Provider in Trouble?

Why CDI Often Times Goes off the Rails

By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM for ICD10 Monitor  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…

Read MoreWhy CDI Often Times Goes off the Rails

Improving Risk Adjustment through Inpatient HCC Capture

By Michelle M. Wieczorek RN RHIT CPHQ for ICD10 Monitor 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…

Read MoreImproving Risk Adjustment through Inpatient HCC Capture
Dolbey Systems, Inc.