Many organizations have HCC tools built into their CDI software or EHRs that can help them capture HCCs. When providers click on a diagnosis or a condition, the tool will mark whether the diagnosis is an HCC. Other technology can extract pharmacy data, lab data, other diagnoses, and the problem...Read More »
By Anny Yuen, RHIA, CCS, CCDS, CDIP, and Page Knauss, BSN, RN, LNC, ACM, CPC, CDEO
The terms “inpatient” and “outpatient” can refer to the clinical setting, but they also indicate the types of procedures performed. Inpatient procedures require that the patient be admitted to the...Read More »
A common theme that plays a critical role in portraying the patient encounter accurately in both the inpatient and outpatient environments is complete and precise documentation. General principles of medical record documentation...Read More »
Vinita Magoon, DO, JD, MBA, MPH, CMQ, presented a poster at the 2018 ACDIS Conference entitled “Using denial data to improve outpatient clinical documentation.” Read More »
Q:Under what circumstances would it be appropriate for a patient who does not meet inpatient criteria to be registered as outpatient receiving observation services?Read More »
By Anny Yuen, RHIA, CCS, CCDS, CDIP, and Page Knauss, BSN, RN, LNC, ACM, CPC, CDEO
The brevity of the patient encounter requires an organization’s outpatient CDI program to focus on improving documentation from the beginning. One of the goals for outpatient CDI should be to reduce...Read More »
By Anny Yuen, RHIA, CCS, CCDS, CDIP, and Page Knauss, BSN, RN, LNC, ACM, CPC, CDEO
Ambulatory surgery and pre-admission testing include pre-scheduled patient visits. Typically, a patient will have a physician order at the time of pre-admission testing, requesting lab work or X-...Read More »
In 2017, we launched a new live event focused on the ever-growing and changing outpatient arena. I’m pleased to announce that we will be hosting the event again in 2018. Next year’s ACDIS Symposium: Outpatient CDI will be bigger and better, but...Read More »