If the hospital documentation, including history and physical and progress notes, doesn't support medical necessity of an inpatient surgical procedure, the physician&'s Part B claim for performing the procedure would be denied. A recent transmittal...Read More »

The American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS) released joint physician query instructions in Guidelines for Achieving a Compliant Query Practice in February 2013.

Nevertheless, a lot of myths...Read More »

The ACDIS California Chapter has been meeting since 2009. Originally three separate groups planned to meet in southern, central, and northern regions of the state to network and share ideas. Such efforts morphed into monthly telephone conference calls which allowed CDI professionals throughout...Read More »