Q: Our physician provided an illegible diagnosis of malnutrition, and when we queried him regarding the specific type of malnutrition, he provided protein malnutrition. The ICD-9-CMCoding Manual directs us to assign code 260;...Read More »
With all the discussion regarding electronic health record (EHR) implementation, many CDI professionals worry that facilities pay little real attention to the collection of meaningful health information or the interconnection of the various electronic tools vendors offer. Added to their concerns...Read More »
Wouldn’t it be nice if every service line in your hospital fully embraced your CDI program’s goals? How frustrating is it when all of the clinical indicators for a given diagnosis are placed squarely under the nose of one of your physicians—only to be...Read More »
The overarching goal of a documentation improvement program is not to improve reimbursement for the hospital, but to effect a positive change in the behavior of those who document in the medical record. This change...Read More »
Attached is a supplement to the April 2011 issue of CDI Journal. It provides important updates every CDI specialist should know regarding new guidance issued in AHA Coding Clinic for ICD-9-CM for both the first quarter of 2011. The author of the article is James Kennedy, MD,...Read More »
ACDIS Associate Editorial Director Linnea Archibald sends out “missed connections” emails with questions from Council members on a regular basis. Anyone with experience related to one of the questions was invited to respond and Archibald connected them with the question-asker. In order to share...Read More »
Clinical documentation plays a vital role in all coding. It is especially important, however, when reporting conditions such as stroke, which more often than not involves multiple symptoms, diagnoses, and complications.
Through the years, The American Hospital Association’s (AHA) ...Read More »
Director’s note, p. 5 Learn how CDI efforts can affect infection control statistics.
Consider opportunities for excisional debridement documentation improvement, p. 6 Trey La Charité, MD, offers advice and a sample query for this RAC target area.
