Composing and documenting verbal query interactions often confuses CDI specialists. While the guidance published by ACDIS and AHIMA holds for all queries, written and unwritten alike, gauging a verbal query’s compliance can be a tricky business.Read More »
Lately, I’ve been sending out emails to chapter leaders across the country asking for their latest updates and giving them a few reminders along the way. I wanted to pass along the information here, too.Read More »
By Karin Killenberger, BSN, RN, CCDS
Working as a remote CDI specialist can be either totally fulfilling or a bit difficult. If you’re a people person, you will miss the camaraderie of working in the hospital setting, the ability to problem-solve by bouncing ideas off your...Read More »
By Drew Siegel, MD, CCDS
One of the more interesting aspects of CDI is taking on the role of a detective to identify and evaluate clues in the medical record that suggest the presence of an undocumented diagnosis, then using these clues to write a compliant and clinically-...Read More »
By Steve Robinson, MS-HSM, PA-O, RN, SSBB, CDIP
When building a successful proactive clinical documentation approach in any patient care venue—inpatient, outpatient, or professional—the effort of setting up communication dynamics is essential and should certainly be a priority.Read More »
By Lori-Lynne A. Webb, CPC, CCS-P, CHDA, CDIP, COBGC
Back in 2016, I wrote the following synopsis for HCPro about outpatient/office diagnosis reporting, clarifying some of the misunderstood procedural guidelines between inpatient and outpatient services....Read More »
Suzanne Megown, RN, BSN, CCDS, CDIP, CCS, is a CDI specialist at St. Luke’s Hospital in Chesterfield, Missouri, and a member of the St. Louis ACDIS chapter, AHIMA, the Missouri component of AHIMA, and eHIMA. A CDI specialist for the past nine years, she worked in pain management...Read More »