Computer Assisted Coding

Chart Conundrums: Desperately Seeking Clinical Validation

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…

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How to Improve Clinical Documentation

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…

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Bridging the Gap between HIM Coding and CDI Professionals

Article by Steven Robinson, MS, PA, RN, CDIP. This article was originally published on the Journal of AHIMA website on April 26, 2017 and is republished here with permission. Unity is strength… when there is teamwork and collaboration, wonderful things can be achieved. —Mattie Stepanek Clinical documentation improvement (CDI) professionals have a worthy task to help identify…

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CDI in the Outpatient Setting: Finding the ‘Hidden Gems’ of Opportunity for Improvement

By Kay Merriweather, RHIA, CCS, CCS-P, COC, CHDA, CDIP; Leslie Slater, RHIA, CCDS, CIC, CRC; and Michele Bohley, RHIA, CCS for AHIMA “If it’s not documented, it wasn’t done.” This is one of the first axioms health information management (HIM) professionals learn. HIM professionals have witnessed the evolution of quality documentation, with patient education becoming…

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Has CAC Lived Up to Its Promise? Providers, Vendors Weigh In

Article by Lisa A. Eramo, MA. This article was originally published on the Journal of AHIMA website on June 1, 2017 and is republished here with permission. In the months leading up to the ICD-10 go-live, many hospitals implemented computer-assisted coding (CAC) in the hopes that it would offset anticipated productivity losses and boost coding accuracy. Now…

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Dolbey to Offer Physician Query Mobile App for CAC and CDI with Artifact Health

Dolbey’s award winning Computer-Assisted Coding application and new Clinical Documentation Improvement offering will now include the power and convenience of mobile physician queries and enhanced query management and reporting through Artifact Health. Dolbey’s Fusion CAC™ is deployed in the medical coding process.  Fusion CAC evaluates the patient chart documentation to suggest diagnostic and procedure codes…

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Dolbey’s Fusion CAC Delivers Fastest Speed-To-Value in ICD-10

CONCORD, OH – OCTOBER 13, 2016 In the recently published study, “Computer-Assisted Coding 2016, Who is Delivering Promised Value in ICD-10” by KLAS Research, Dolbey customers reported the fastest ICD-10 speed-to-value. With the implementation of ICD-10, most healthcare organizations experienced a decline in coding productivity which results in higher unbilled accounts receivables. Dolbey customers, using…

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Words Matter: Best Practices for Dictating in an EMR Setting

By Selena Chavis for For The Record Vol. 28 No. 4 P. 14 As HIT matures, dictation and transcription models continue to evolve. It’s a situation being closely monitored by health care organizations concerned about the fallout from potential productivity losses and physician outcry over clunky EMR documentation workflows. To combat these fears, many facilities are…

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ICD-10 to Get 5,500 New Codes, Including Ones for Face, Hand Transplants, CMS Says

By Susan Morse for Healthcare IT News CMS said it plans to add about 1,900 diagnosis codes and 3,651 hospital inpatient procedure codes to the coding system. On Oct. 1, the Centers for Medicare and Medicaid Services will add another 5,500 codes to the ICD-10 diagnostic library, officials announced in a March 9 meeting. The addition will…

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Take Advantage of Expanded External Cause Codes in ICD-10

By Cathie Wilde, RHIA, CCS, AHIMA-Approved ICD-10-CM/PCS trainer for ICD10 monitor Monday, 11 January 2016 During the transition to ICD-10, external cause codes – the codes that capture specific details about an injury or health event – received a bad reputation. Many ICD-10 naysayers highlighted what they viewed as the absurdity of them. In an…

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