A few weeks ago, I was giving a presentation to a group of surgeons. I was talking with them about CDI, which as you might imagine is as near and dear to the heart of the surgeon as mindfulness is to Daffy Duck. My comments engendered a...Read More »
Q: I encountered clinical validation issues where documentation noted a diagnosis with criteria, but the criteria used didn't meet the definition. For example, noted sepsis with criteria of tachycardia and increased white blood cell (WBC) count. But, the patient’s heart rate (HR...Read More »
By Susan Wallace, MEd, RHIA, CCS, CDIP, CCDS, FAHIMA
Believe it or not, the Federal Register is one of the best crystal balls to foresee the future of CDI.Read More »
No new hospital initiative operates in a vacuum. And there is no way to anticipate every consequence of your CDI program. Even with the best intentions, there will be downstream consequences to navigate.
Q: What should we do about the documentation of “acute pulmonary insufficiency?” What indicators are you using for this in comparison to querying for acute respiratory failure? Acute pulmonary insufficiency is an MCC following surgery but it is also a potential patient safety indicator (...Read More »
The basic tenant of learning CDI is learning how MS-DRGs work, and the tiered structure of CC and MCC levels. That is the first step, to be sure, but it is not the final destination. In the new era of quality based reimbursement, there are...Read More »
By Marion Kruse, BSN, RN, MBA, and Jennifer Cavagnac, CCDS
Every CDI program should objectively evaluate the outcomes, processes, and compliance of their CDI efforts. Auditing and monitoring provides oversight for the CDI program, insight into physician documentation and...Read More »
