Though many coders and auditors say so, there is no official direction that states diagnoses can only be reported if they’re included in the discharge summary. We teach in our CDI Boot Camps that, although it’s desirable if the...Read More »
By Rebecca Hendren
Outpatient CDI is a fast-growing area of focus for those working in the field. In a recent member poll, 33% of our audience reported that they either have an outpatient CDI program or they are planning to launch one within the next 12 months.Read More »
CMS released a change request May 30 describing changes which will be implemented in the July 2017 quarterly update to the outpatient prospective payment system (OPPS...Read More »
Take a close look at the documentation guidelines that CMS suggests for the practice improvement portion of the merit-based incentive payment system (MIPS) and you may ward off future audits and avoid forfeiting revenue, according to the...Read More »
Those who’ve been in CDI long enough remember the days of colored paper queries slipped into charts. Often, those queries would get lost in the literal shuffle, or simply go unanswered and ignored with no concrete way of tracking the query. Then, electronic health records (EHR) came on the scene...Read More »
Q: I’m running into a big problem with the nursing documentation. The nursing notes have inconsistent documentation of lung assessment, missing documentation when it comes to the patient being on room air or oxygen (O2), and the intakes...Read More »
This past month was a busy one on the ACDIS Forum. From outpatient CDI, to clinical and coding, to pediatrics, the Forum had a conversation for everyone in every type of CDI program.Read More »