Q: Is there guidance on reviewing a record, such as an operative (OP) note, that has not been signed by a physician? I am at a facility that allows coding from unsigned transcriptions. I was always told that the information needs to be confirmed by a signature as valid before including...Read More »
Are you looking for a quick and easy way to engage your providers? Homemade baked goods and gifts recognizing consistent high quality documentation are a viable option. But, while treats are great for some, the best strategy for motivating providers can, in many cases, be their own track records...Read More »
When it comes to dinner-party small talk, CDI professionals often struggle to find an easy sound-bite explanation to the role they play within the healthcare system.Read More »
Local chapters are accepting nominations for leadership positions. This is your chance to share your passion for clinical documentation improvement, have a voice within ACDIS, and support your CDI community. Read More »
Q: CMS released guidance this summer about not auditing or counting errors for the specificity of an ICD-10-CM code. CMS is not going to count the code as an error as long as the first three digits are correct. Does this apply to medical necessity diagnoses and edits. Read More »