Have you ever read a history and physical (H&P) report and wondered why the patient was admitted? Have you ever wondered which diagnoses were resolved prior to admission?
If you are a CDI specialist or coder you’ve probably struggled...Read More »
There are now nearly 1,000 professionals who possess the Certified Clinical Documentation Specialist (CCDS) certification. Congratulations to all those who have taken the courageous step to sit for the exam and passed.
As a reminder, maintaining your certification requires
A date for the potential ICD-10 implementation deadline may be released soon. The Office of Management and Budget (OMB) is currently reviewing the HHS proposed rule, “Administrative Simplification: Standard Unique Identifier for Health Plans and ICD-10 Compliance Date Delay.” The OMB’s review is...Read More »
CMS chose not to include code 428.0 (congestive heart failure, unspecified) as a CC in the IPPS Final Rule released August 1. That disappoints ACDIS Advisory Board member James S. Kennedy, MD, CCS, CDIP,...Read More »
CDI specialists should review the overall quality of medical record documentation from the day a patient comes into the ER—regardless of whether that patient ultimately ends up in observation, as an inpatient, or elsewhere.
“Quality of care is not segregated into buckets,” says Glenn...Read More »
Q: If a hospital CEO were to tell a new CDI department manager to pull together some statistics on the performance of the department, where should he or she begin?
On August 27, CMS launches its Recovery Audit Prepayment Review demonstration project. Over the next three years, the agency will contract with auditors to review medical records prior to payment.
Originally announced in November 2011, the project was delayed from its...Read More »
