Physicians are constantly reminded that healthcare is undergoing significant change. October 2015 marked one more landmark change: the shift to ICD-10. Many physicians have worried about the transition and likely dreaded the loss of familiar...Read More »
Many clinical documentation improvement (CDI) specialists with clinical backgrounds are encoder dependent, trained to “code” using an encoder and taught to create a working MS-DRG based on grouper software. Many coders also rely on the...Read More »
The incidence sepsis cases within the United States has quadrupled while the length of stay of these cases and the mortality has decreased. And Recovery Auditors have denied numerous claims because, at least in part, CDI staff queried to get sepsis DRGs when...Read More »
I was recently discussing the state of EHRs in regard to the poor quality of the documentation with a colleague who has been a practicing HIM professional for more than 35 years and currently works for a large group of hospitals as the...Read More »
Catholic Health Services of Long Island (CHS) started its CDI program at St. Francis Hospital in Roslyn, New York, back in 2006. For anyone who’s met the dynamic director who started the program back then, it may come as little surprise that Adelaide La Rosa, RN, BSN, CCDS, since expanded the...Read More »
Coronary artery disease (CAD) develops when the arteries that supply the blood to the heart muscles become hardened and narrowed due to a buildup of cholesterol and other materials, such as plaque, on their inner wall. It’s also called...Read More »
ICD-10 CM/PCS. To some, the utterance of this classification system produces much trepidation. I hope to dispel some concerns as I recount the undertaking of ICD-10 implementation at one CDI program.