by Cheryl Ericson, RN, MS, CCDS, CDIP and Cathy Farraher, RN, MBA, CCM, CCDS
Clinical validation is a process in which diagnoses already written in the chart are reviewed by a clinical documentation specialist to ensure the corresponding clinical indicators and treatment exist...Read More »
by Tracy Boldt, RN, BSN, CCDS, CDIP, and Ellen Jantzer, RN, MSN, CCDS, CCS, CRC
The rules of compliant query practice do not change based on the setting. We must consider query construction and wording of provider communication with the same eye for compliance as we have...Read More »
by Tracy Boldt, RN, BSN, CCDS, CDIP and Ellen Jantzer, RN, MSN, CCDS, CCS, CRC
Physician support in the CDI decision-making process from the CDI program’s inception helps physicians see beyond the immediate obligation of documentation to the greater good such documentation...Read More »
The third character of a procedure code is represented by the root operation. Definitions for the root operations are located in Appendix A and within the tables of the ICD-10-PCS manual.
When the same root operation is performed on different body parts represented by distinct characters...Read More »
by Cheryl Ericson, RN, MS, CCDS, CDIP and Cathy Farraher, RN, MBA, CCM, CCDS
From the outset, crafting appeals for clinical validation should follow the format established by the facility denials management team for any other appeal. Best practice for the opening paragraph is to...Read More »
Documentation and coding myocardial infarction (MI) is a common pain point for CDI departments, caused by conflicting or incomplete documentation that requires further clarification with a query. Type 2 MI is frequently incorrectly diagnosed and...Read More »
