Tag Archives | CDI

Emergency Care: CDI in the ED Part II

EDITOR’S NOTE: This is the final installment in a two-part series on clinical documentation integrity (CDI) in the emergency department (ED). It is my opinion that investing CDI resources into the neglected stepchild that is the hospital system ED is a worthwhile endeavor. Getting diagnoses captured early and repeatedly creates performance improvement. Even more importantly, […]

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ICD-10 New Codes: Pressure Mounts as Deadline Approaches When New Codes Become Effective

Now it’s just a little less than three weeks until the beginning of October and when the fiscal year (FY) 2018 changes for ICD-10-CM take effect. Here is a summary of the new changes for ICD-10-CM: 360 new code additions 142 deletions 250+ revisions The Centers for Medicare and Medicaid Services (CMS) published a variety […]

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ICD-10 Gets Down to Specifics, and Attention to Detail Directly Affects Finances

This year, getting reimbursed is all about making sure the codes reflects the actual care given. For ICD-10 changes this year, the devil’s in the details. When ICD-10 was first implemented on Oct. 1, 2015, it was a nail-biting flip of the switch and then a sigh of relief when denials didn’t mount up as […]

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Conditions That Risk-Adjust for Inpatients Not Always the Same for Outpatients

Last week Tracy Boldt contacted me to ask a question about outpatient clinical documentation integrity (CDI), and we are lucky to have her on the Talk-Ten-Tuesdays broadcast today, detailing Essentia Health’s successful outpatient CDI program. She also mentioned that she had been awaiting the third installment of my three-part series on outpatient CDI. I was […]

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Does a CDI Program Improve Physician Engagement?

Last month, the American Health Information Management Association (AHIMA) released a practice brief titled “Impact of Physician Engagement on Clinical Documentation Improvement Programs.” The brief contains some extremely valid and interesting points. Genuine, consistent physician engagement is essential for any clinical documentation improvement program meant to achieve scale and long-term sustainability. The practice brief starts […]

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Some New Myocardial Infarction Codes Challenge Interpretation

The addendum for new codes coming out was recently released with many notable additions and deletions. The next several articles in this series will address some of these conditions in order to help us get ready for the October 1 implementation date. One of the things I love most about getting the codes well before […]

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Clinical Documentation Integrity: Where Business Acumen Governs High Performance

Clinical documentation integrity (CDI) as a profession is quite similar in nature to running a business. Successful businesses exhibit certain operational qualities and traits that serve to ensure continued growth and prosperity, and their leaders possess a long-term vision and ability to consistently meet, exceed, and solidly predict current and future needs of their customers. […]

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Outpatient CDI: Is “Outpatient” Out? Part I

There is a great push within the healthcare industry to move clinical documentation integrity (CDI) into the outpatient arena. People refer to this as “outpatient CDI,” but I think this is a misnomer. If you plan on stationing CDI specialists (CDISs) in physician offices, that could be construed as “outpatient CDI,” but I believe the […]

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Outpatient CDI: Is it an Offshoot of Traditional CDI Programs?

There has been a wide array of discussion through published articles, forums, webinars, and meetings about the topic of outpatient clinical documentation improvement (CDI) programs. Outpatient CDI is receiving much attention and experiencing traction in the healthcare industry due to providers coming to terms with the fact that documentation truly matters from a financial perspective, […]

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Remote CDI: A Remote Possibility?

During a recent edition of Talk Ten Tuesdays, Dr. Erica Remer responded to a listener’s question about clinical documentation integrity specialist (CDIS) working remotely. Here is Dr. Remer’s response. As I tell residents, historically, charting and chart review was done on the floor, because that’s where the chart was. Clinical documentation integrity specialists (CDISs) and […]

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What’s the Key to Better ICD-10 Coding?

Nearly a quarter of all U.S. hospitals now outsource some or all coding functions. Ninety percent of hospitals over 150 beds currently outsourcing their CDI processes reported in Q3 to have realized significant (over $1.5M minimally) in appropriate revenue and proper reimbursements following the implementation of clinical documentation improvement programs in this past year following […]

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