(See p. 4) ACDIS has issued comments to AHIMA, CMS, and the Centers for Disease Control and Prevention, but it’s largely been a shared responsibility and not the purview of a committee chair or elected officer, for example. We’ve also been asked to take a look at our elections process and ways...Read More »
Q: Are there any coding guidelines/definitions regarding code 518.5 (Pulmonary insufficiency following trauma and surgery) vs. the use of 518.81 (Acute respiratory failure postop)? If a physician documents postop respiratory failure, which code should we report? I looked in Coding Clinic...Read More »
CDI specialists should know what to look for when reviewing cancer admissions in order to capture the true severity of these patients’ illnesses. Often patients are discharged with the diagnosis of “possible” or “probable” cancer when the pathology report is...Read More »
After four years of studying the intricacies of the medical transcription industry, Gary C. David, PhD, associate professor of sociology and associate professor of information design and corporate communication at Bentley University in Waltham, MA, has turned his attention to CDI. David is in...Read More »
With all the discussion regarding electronic health record (EHR) implementation, many CDI professionals worry that facilities pay little real attention to the collection of meaningful health information or the interconnection of the various electronic tools vendors offer. Added to their concerns...Read More »
Wouldn’t it be nice if every service line in your hospital fully embraced your CDI program’s goals? How frustrating is it when all of the clinical indicators for a given diagnosis are placed squarely under the nose of one of your physicians—only to be...Read More »
The overarching goal of a documentation improvement program is not to improve reimbursement for the hospital, but to effect a positive change in the behavior of those who document in the medical record. This change...Read More »
Attached is a supplement to the April 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 both the first quarter of 2011. The author of the article is James Kennedy, MD,...Read More »