By the time you’re reading this note, the first-ever Clinical Documentation Improvement Week will be in the record books. I hope you made the most of it.
Almost since the start of ACDIS back on October 1, 2007, our members have been asking (“clamoring” might be a better word) for a week...Read More »
Documentation of both malnutrition and body mass index (BMI) affects MS-DRGs’ assignment as CCs or MCCs and can clarify the patient’s SOI as well as the complexity of care required to treat him or her. Understanding the interrelationship between BMI and malnutrition as well as the clinical...Read More »
It did not take Bonnie I. Epps, MN, RN, manager of the CDI department at Emory Healthcare, Inc., in Atlanta,long to realize that staff physicians were not quite chomping at the bit to answer her team’s queries. To raise awareness, she quickly created a multifaceted educational approach and...Read More »
There are a number of ways to get CDI information into the hands of your facility’s physicians. The following list offers a number of suggestions on how to train and engage your medical staff.Read More »
Q: Some physicians are uncomfortable making addendums to the discharge summary to include the pathological findings (e.g., malignancy). Instead, they dictate a tumor board note to summarize the course of treatment and final pathological diagnosis. However, the tumor board note is usually dated...Read More »
by Jonathan Elion, MD, FACC Inappropriate use of baseline metrics may be inadvertent,but it can result in reports that show an inflated and unrealistic effect of the CDI program on overall facility performance. Furthermore, many CDI programs leave the data analysis to an outside...Read More »
Radiology reports, such as CT and MRI scans, x-rays, and ultrasounds, frequently contain detailed information that can lead to more specific code assignment. Coding Clinic advice supports the use of radiology findings to obtain additional...Read More »
Attached is a supplement to the July 2011 issue of CDI Journal. It provides important updates every CDI specialist should know regarding new guidance issued in AHA Coding Clinic for ICD-9-CM for the second quarter of 2011. The author of the article is James Kennedy, MD, CCS, of FTI...Read More »
