Director’s note, p. 5 Learn how CDI efforts can affect infection control statistics.
Consider opportunities for excisional debridement documentation improvement, p. 6 Trey La Charité, MD, offers advice and a sample query for this RAC target area.
As the financial tug-of-war continues, with government and private payers on one side and healthcare providers on the other, it can be difficult for CDI staff to know where the bright white line of ethical behavior begins. This is one reason AHIMA released its Ethical Standards for Clinical...Read More »
You’ve heard it in the media: Hospitals are making people sick and/or causing unnecessary complications. While the problem is much more complex—often a clash of clinical terminology vs. documentation and coding regulations—hospitals are stuck in the middle and come out looking like an easy-to-...Read More »
by Trey La Charité, MD
Every institution reading this column has likely received its first recovery audit contractor (RAC) denials regarding the documentation and coding of excisional debridement procedures (86.22).
Our hospital is no exception. While we knew that this...Read More »
As of January 1, a dozen ACDIS advisory board members will step down after leading the organization they helped create three years ago.This diverse group infused the association with a wide breadth of expertise and also reinforced the fact that CDI is not limited to nursing or HIM professionals...Read More »
Learning how documentation opportunities can maximize efficiency and overall cost-effectiveness is something to be passionate about. Working as a patient care nurse was extremely rewarding, but as a CDI professional I am now able to affect my...Read More »
This is a classic documentation opportunity to clarify “volume/fluid overload,” says Lynne Spryszak, RN, CPC-A, CCDS, CDI education director for HCPro, Inc., in Danvers, MA. “If the physician hasn’t documented acute CHF, I would hesitate to ask for this condition based on this mild BNP elevation...Read More »
Few managers have the luxury of hiring staff with concurrent record review experience. Thus, once you hire new staff, you need to determine how to train them. Even if the new hire is an experienced nurse who understands core measures, “you can’t just throw him or her a problem list and set them...Read More »
