It is hard to believe that the first-ever Clinical Documentation Improvement (CDI) Week is now little more than a pleasant memory for most. It was definitely something to be marked in the annals of ACDIS’ history. The first CDI Week may be over, but the days of recognizing this unique, vital...Read More »
The first annual Clinical Documentation Improvement Week was celebrated September 18–24, 2011. A work group organized and supported by ACDIS convened over several months to plan and organize the event and to develop resources and promotional events, including an industrywide survey and a series...Read More »
Q:My question has to do with coding guidelines regarding secondary diagnosis followed by contrasting/comparative diagnoses. Let me explain a particular scenario. This was a two-day stay over the weekend. The patient was admitted for further evaluation with a history and...Read More »
Determining when to seek clarification regarding patients with altered mental status can be tricky business. Patients who already have established dementia and are now off their baseline with an acute metabolic disorder such as UTI, physicians are typically...Read More »
For providers, the days of earning full Medicare payment by simply submitting complete and accurate information are drawing to a close. In 2013, Medicare will begin paying healthcare providers and facilities based on the quality of care provided, not...Read More »
Q: For some reason, I was under the impression that a query could be answered by any healthcare provider, even one just doing a review of the case (a fellow hospitalist, for instance). I know that a treatment provider is, of course, the way to go but was wondering about this as...Read More »
Most coders know that reporting a complication of care requires that the medical record include explicit documentation of the relationship between the condition and the procedure. Previous versions of the ICD-9-CM guidelines include this requirement in Chapter 17 (Injury and Poisoning),...Read More »
