Officially, the CDI specialist’s role is to facilitate accurate, complete, and consistent clinical documentation within the health record to demonstrate the quality of the care provided and to support coding and reporting of high-quality...Read More »
Lisa Farhar, RN, MSN, MBA, CCDS, is an advisory specialist at Deloitte and Touché, LLP, in Indianapolis, Indiana, and a member of the Indiana ACDIS local chapter.Read More »
Q: We recently had a patient come in with bilateral shoulder pain and numbness. The patient also had lung cancer, metastasized to spine. What should we sequence as the principal diagnosis? The patient is currently undergoing chemo therapy. Read More »
Just like that, spring has come and gone and summer is upon us. While the summertime holds vacations, beach days, and bonfires, there are also a number of ACDIS local chapter and national events coming up to help you connect with your peers outside the office.Read More »
Many CDI specialists come from a purely coding background, while others who have a purely clinical background seek additional education in the coding realm and have attained certification in the field of coding. Regardless of the...Read More »
Physician advisors do everything from providing pre-/postbill clinical documentation support to assisting with Recovery Auditor (RA) appeals and drafting appeal letters to reviewing charts for medical necessity of inpatient admissions.Read More »
Q: I’ve heard that the provider should identify the level of substance consumption. For provider education, would the CDI department need to cite any clinical indicators that would help providers differentiate use, abuse, or dependence? Or should we...Read More »
By Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS
A commonly recommended audit sample size is 30 cases for routine quality auditing with no known serious compliance issues. Conducting an audit of this magnitude for every coder every month can be a daunting challenge....Read More »