By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS
At the 2017 ACDIS conference in May, Nelly Leon Chisen, RHIA, director of coding and classification, the executive editor of the American Hospital Association’s (AHA) Coding Clinic ...Read More »
Once the patient is discharged, it is the coding team’s time to shine. If the hospitals’ providers and clinicians have an electronic health record (EHR) that uses natural language processing (NLP)...Read More »
By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS
The 2017 Official Guidelines for Coding and Reporting, effective October 1, 2016, contained a new, perplexing, and problematic section I.A.19 titled “Code Assignment and Clinical Criteria,” which states:...Read More »
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 »
