Q: Our coding team has established their own clinical criteria for a specific diagnosis despite what the physician is documenting and the clinical validity of those diagnoses. Could you please advise?Read More »
CDI professionals often work with physicians and coders, but record reviews also lend themselves to collaboration with case management. Part of a case manager’s job is to look at documentation in the medical record from the standpoint of medical necessity, meaning the justification for the...Read More »
By Julian Everett, BSN, RN, CDIP
I clearly remember the day my director told me I’d be reviewing our pediatric mortality cases. I didn’t know where to begin, and our pediatric CDI program was only a year old. Before I could start tackling the problem, I had to learn as much about...Read More »
With more than 40 local chapters, networking groups, and even international CDI efforts related to ACDIS, some are surprised to learn that there is no direct financial relationship between the national organization and these component groups.Read More »
by Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS
In response to providers’ complaints of burdensome regulatory documentation, CMS proposed in July 2018 to reduce the number of evaluation and management (E/M) levels to two and reduce documentation requirements for...Read More »
A quarter of respondents call their CDI program’s relationship with coding “fair” or “poor” according to a September 26, 2018, ACDIS Radio episode. Despite being called the bridge between the coding and clinical worlds, CDI professionals frequently need to build or repair their relationship with...Read More »
Even on a small scale, knowing where to start with an outpatient CDI program implementation can leave leaders at a loss. Add in the complications of a large healthcare system and things can get even hairier. With multiple sites and teams dispersed geographically, there’s a lot to consider before...Read More »
by Tammy Trombley, RHIT, CDIP, CCDS
Recently, an outpatient CDI review project at a large family practice/internal medicine physician clinic identified numerous coding errors on physician-coded claims. More than half of the errors affected risk adjustment for the CMS-Hierarchical...Read More »