Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of revenue cycle because independent providers must document according to intricate and...Read More »
Summer is finally here! It’s been a long-time coming for New Englanders! I contrast the abundance of this wonderful, although too brief, season with all the enhanced CDI insight and transition to current practice.Read More »
Long before ICD-10-CM/PCS became a focus, working as a clinical documentation improvement (CDI) manager to improve physician progress and/or operative notes was a challenge—doctors either got it or they didn’t. But as the transition from...Read More »
Experts agree that a collaborative healthcare environment leads to better patient outcomes and improved organizational success. Despite this, long-standing tensions between nurses, coders, CDI specialists, and physicians can be difficult to overcome.
Though team training can do a lot of...Read More »
Every CDI specialist knows how difficult it can be to set aside a whole hour or more for dedicated training and education. With productivity expectations and quotas, cutting out a sizable chunk of time for learning can be challenging. Diversifying CDI education tactics can help engage staff in...Read More »
Q: What guidance do you have for building a denial management team?
A: As with any team, it is important to have the right players working together with identified roles and responsibilities established for each. The members of the denials management team...Read More »
Determine the underlying cause of the altered mental status
Remember that the various forms of altered mental states have underlying causes, which, if defined, diagnosed, and documented, accurately represent the patient’s...Read More »
