The beginning of the year is a time to go back to basics—or even, in some cases, to start over. The last white paper published in 2019 focused on preparing CDI professionals for that exact purpose. Titled “How to conduct a medical record review,” it takes CDI professionals back to the core of...Read More »
The HHS draft strategy to reduce EHR burdens lists several elements related to clinical documentation principally focused on previous recommended changes to E/M...Read More »
According to a recent ACDIS poll, 58% of respondents currently conduct retrospective chart reviews, and another 5% say they have plans to expand into retrospective reviews soon. While some of those 58% review pre-billing and others post-billing, the goal for retrospective reviews remains the...Read More »
Q: Our physician advisors are requesting the question and options be listed before the clinical indicators and treatment in the query. I could not locate any direction regarding this format in the current ACDIS/AHIMA physician query practice...Read More »
Q: Our coding team has established their own clinical criteria for a specific diagnosis despite what the physician is documenting and the clinical validity of those diagnoses. Could you please advise?Read More »
ACDIS is built by many hands outside of the full-time administrative team. While in years past, we’ve put out individual calls for our ACDIS boards and committees, this year we’re trying something a little different: We’re calling for...Read More »
CDI professionals often work with physicians and coders, but record reviews also lend themselves to collaboration with case management. Part of a case manager’s job is to look at documentation in the medical record from the standpoint of medical necessity, meaning the justification for the...Read More »
If one of your New Year’s resolutions was to get more involved with CDI and ACDIS, we have a suggestion for you: The Journal is ACDIS’ bimonthly publication which includes regulatory information, news, clinically-based articles, case studies, and membership profiles. Many of those...Read More »
