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By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor Is your Electronic Medical Record (EMR) system helping you pass an audit or hurting you? Editor’s Note: This is the third piece in a four-part series that examines physician documentation issues as seen by an auditor. Click here…
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. The issues are the chief complaint and HPI. Editor’s Note: This is the second piece in a four-part series that examines physician documentation issues as seen by an auditor. Click here…
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…
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…
By Naseem S. Miller for Orlando Sentinel The number of babies who were exposed to opioids in the womb jumped by 200 percent in Florida between 2015 and 2016 — to more than 2,500 cases — the biggest spike in the past decade, according to state data. But the number of newborns statewide who were…
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…
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…