On October 14, we reported that CMS issued a controversial MLN Matters special edition (SE) article which stated that all inpatient admissions needed to have any/all ‘other’ or ‘secondary’ diagnoses documented by the attending physician.
In the spring, AHIMA released its “Guidance for Clinical Documentation Improvement Programs” in the Journal of AHIMA and also published its 41-page Clinical Documentation Improvement Toolkit. The documents offer sample job descriptions, definitions for documentation clarifications...Read More »
CDI specialists need to use all the tools available in their documentation training box to effectively change physician behavior. Educational sessions are helpful, particularly when followed by effective queries targeting the same educational issue. Combine this approach with e-mail newsletters...Read More »