Q: Payers have been pushing back when a diagnosis appears in the discharge summary and not in the chart. Can the physician add a late entry or addendum into the medical record by way of a progress note or an addition to a discharge summary...Read More »
Shortly after releasing its Clinical Documentation Improvement Toolkit in April, the American Health Information Management Association (AHIMA) released its Guidance for Clinical Documentation Improvement Programs in the May issue of the Journal of AHIMA.
CMS has been holding a number of open forum calls regarding its Recovery Audit Contractor (RAC) programs. Dubbed “Nationwide RAC 101 Calls” these sessions covered the basics of RAC reviews, each focusing on a different provider area.
The first call on April 28, intended for all acute...Read More »
Effective January 1, 2011, CMS will start to accept up to 25 codes for secondary diagnoses. The change, listed in a March 2010 MedLearn Matters article and also listed in the...Read More »
CDI specialists are getting too tied up with the minutiae of ICD-9-CM coding and DRG optimization instead of focusing on the overall clinical picture of the patient and the integrity of the medical record, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, an independent...Read More »
The American Health Information Management Association (AHIMA) published its Clinical Documentation Improvement Toolkit earlier this month. The 41-page document offers sample job descriptions for CDI specialists and physician advisers to CDI, provides definitions for documentation...Read More »
Despite the inclination of many hospital administrators to mechanize documentation and abstraction of quality measures, Kristen Geissler, MS, PT, MBA, CPHQ, associate director in the Healthcare Clinical Economics Practice at Navigant Consulting, Inc., in Baltimore, hasn’t heard of anyone able to...Read More »