A recent ACDIS poll asked “which type of professional comprises the majority of your CDI program chart reviewers?” The greatest number of respondents (66%) indicated they primarily employed registered nurses (RNs)...Read More »
Recently, Robert S. Gold, MD, estimated that 60% of facilities nationwide implemented CDI programs, a best guess derived from an initial ACDIS survey taken in 2007 which put the percentage of acute care facilities with CDI programs at roughly 50.
Q:Our program does not typically include query information as part of the medical record. If the physician responds to a faxed query, we scan the fax into our electronic record. However, we resolve most queries in person or through a secure messaging system in our EMR (...Read More »
CMS released the long-anticipated proposed rule for Medicaid recovery audit contractors (RACs) Friday November 5, setting the stage for the targeted April 2011 implementation date.
The use of Medicaid RACs is another initiative put forth by CMS as part of the Affordable Care Act—...Read More »
On October 14, we reported that CMS issued a controversial MLN Matters special edition (SE) article which stated that all inpatient admissions needed to have any/all ‘other’ or ‘secondary’ diagnoses documented by the attending physician.
In the spring, AHIMA released its “Guidance for Clinical Documentation Improvement Programs” in the Journal of AHIMA and also published its 41-page Clinical Documentation Improvement Toolkit. The documents offer sample job descriptions, definitions for documentation clarifications...Read More »
CDI specialists need to use all the tools available in their documentation training box to effectively change physician behavior. Educational sessions are helpful, particularly when followed by effective queries targeting the same educational issue. Combine this approach with e-mail newsletters...Read More »
Q:I have heard that some facilities have seen their number of generated queries actually increasing rather than decreasing over time. Generally, we hope that by improving the documentation concurrently, we would decrease the need to ask the questions retrospectively. If...Read More »
