Third-party regulatory agencies often question the clinical validity of a physician’s diagnosis. Most hospitals have had a Recovery Auditor deny a claim due to lack of documentation identifying supportive clinical indicators in the medical record. But until recently, CDI specialists and coders...Read More »
Let’s face it: CDI is a large and growing profession in part because it increases hospital case-mix indexes and reimbursement. A good CDI program leads to accurate documentation of specific diagnoses, resulting in a more accurate representation of a patient’s severity of illness, and better...Read More »
Timothy N. Brundage, MD, CCDS, is a diplomate of the American Board of Internal Medicine and the principal of Brundage Medical Group, LLC (BMG). He has been a member of the ACDIS Advisory Board since 2011. He and his wife, Patty (a nurse practitioner who helps with CDI efforts of BMG), are...Read More »
What is the goal of a CDI program? Most of the ones I see still focus on DRG optimization. We need to make the physicians allies of our CDI programs, and right now they are not. Instead, they are often targets of our queries. So how do you make the transition? By changing physician behavior one...Read More »
When Kari S. Ellis, RN, accepted a CDI position at the small, 100-bed Daviess Community Hospital in Washington, Ind., she had no documentation improvement experience. So when Ellis reached out, Terri Leap, RN, BSN, MBA, CDI specialist at Wishard Hospital in Indianapolis began to consider...Read More »
On the surface, defining acute respiratory failure seems to be a relatively straightforward task. However, many providers find it difficult to arrive at this diagnosis without repeated queries from the CDI specialist. The discussion and examples that follow...Read More »
CDI initiatives often focus on inpatient documentation to ensure that the documentation accurately reflects patient severity. Capturing that documentation and specificity will be even more important as ICD-10 preparation and implementation efforts get underway. Yet ICD-10 implementation will...Read More »
