Changes in the IPPS (Inpatient Prospective Payment System) led hospitals to develop clinical documentation departments to assist with these changes. Some hospitals hire consultants to initiate their novice CDI staff. They provide generous budgets to...Read More »
When AHIMA released its “Managing an Effective Query Process” brief in September 2008, it raised a number of concerns among them the responsibility of a CDI program to draft consistent policies and procedures for conducting physician queries. In...Read More »
Good communication is a key attribute of a successful clinical documentation improvement specialist (CDIS). The CDIS must be able to function in a variety of different settings. These include the CDIS office, the patient care unit, and presenting at rounds....Read More »
Q: We have been educated by our coding staff not to use the residents’ notes except as a guideline. They have said that they can only code the record from the actual attending documentation. We try to get physicians to co-sign the resident notes, and sometimes they do and sometimes they...Read More »
Does it sometimes seem like wound and pressure ulcer documentation is a movable feast? I’ve spent a lot of time scrutinizing wound documentation lately in anticipation of the new pressure ulcer codes being implemented October 1st and sometimes I...Read More »
Preface to the following: You won’t find a stauncher advocate for ethical behavior in the documentation compliance profession than me. I firmly believe that documentation compliance is all about quality, specificity, and the behaviors and...Read More »
