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 »
By Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC
One pitfall many CDI professionals face is one I faced myself in my early years. As a young CDI professional, I stressed to everyone, “I am not a coder.”
I still say that to people who ask me very specific questions related to...Read More »
“DRG validation can mean many things in many different arenas,” Autumn Reiter, RN, BSN, CCDS, CDIP, CCS, director of CDI staffing services at TrustHCS, said on the January 3 episode of ACDIS Radio, “New approaches in DRG validation.” “Essentially, it’s ensuring a correct final...Read More »
Q: According to Official Guidelines for Coding and Reporting, uncertain diagnoses should be documented at the time of discharge. If a consultant documents an uncertain diagnosis in the final or last progress note and no discharge...Read More »
Jose M. Gonzalez O’Neill, MSHIM, RHIA, is the vice president of the Florida ACDIS chapter, and HIM service line manager for medical transcription and inpatient coding at a large hospital system in the Orlando area.Read More »
Sepsis’ complexity and frequent definition updates propose challenges for CDI and coding professionals but it’s also a gray area in clinical medicine.Read More »
