CMS will provide a a basic introduction to ICD-10-CM during its National Provider Conference Call of Tuesday, March 23, from 1-2:30 p.m. (EST). The call will discuss the requirement to report ICD-10, outline the benefits of the switch from ICD-9, discuss general structural differences between...Read More »
Although AHIMA’s October 2008 practice brief “Managing an Effective Query Process” clearly states that the agency intended the article as guidance, not regulation, CDI programs should regularly review their query practices, policies, and procedures to determine if any problem areas may need to...Read More »
For CDI specialists, the physician signature is one more critical piece of documentation to keep an eye on. Actually, it’s one of primary reasons to query the physician according to the AHIMA physician query practice brief, “Managing an Effective Query Process”. CMS Transmittal 326 (Change...Read More »
Like many CDI specialists, Janice Davis, RN, clinical documentation analyst at High Point (NC) Regional Health System and her four co-workers struggled with obtaining appropriate documentation for chronic kidney disease (CKD) and acute renal failure (ARF). “So we decided if we listed the...Read More »
More than 300 CDI specialists participated in the 2009 ACDIS salary survey. Respondents answered questions about CDI specialists’ compensation (most make between $50,000 and $70,000 on average), their program structure (most CDI programs...Read More »
The concept of standard operating procedures (SOP) might easily call to mind assembly lines or retail-related employee handbooks. But CDI programs should establish such basic operating policies to clarify expectations for CDI staff and the healthcare professionals who interact with them....Read More »
CDI specialists are charged with reviewing concurrent medical records on the hospital floor and clarifying clinical documentation when appropriate. I emphasis the term “appropriate”because there hardly seems to be a time when the opportunity for a clinical query does not exist....Read More »
Q: Do you code the procedure for tissue plasminogen activator (tPA) administration when it is done in your emergency room for patients being admitted with cerebrovascular accident (CVA)/stroke on inpatient cases?