Q: What are some documentation gaps in behavioral health encounters?
A: Many times, we see a lack of specificity regarding symptoms, severity, and treatment details required for accurate ICD-10-CM coding, as well as incomplete...Read More »
Generative artificial intelligence (AI) offers benefits in medicine but poses risks to medical trainees, including skill loss and outsourcing reasoning that can potentially undermine clinical competence and patient safety, according to a recent...Read More »
According to a clinical review published in the Journal of the American College of Cardiology, atherosclerotic cardiovascular disease remains a leading cause of morbidity and mortality worldwide, with acute myocardial...Read More »
Q: I primarily work in the neurosurgery review lane within CDI and am seeking further guidance on best practices for capturing loss of consciousness (LOC) status in cases of traumatic subdural or subarachnoid hemorrhage. Current definitions of LOC appear broad and can be challenging...Read More »
9 Fortifying encephalopathy: Strengthen every link on the chain 17 Bridging the clinical/coding gap 24 PSI exclusions and review structure: Advice from the...Read More »
The most well-attended track at the ACDIS conference year-over-year has always been its first, titled “Clinical & Coding.” Most CDI professionals come from a clinical background and have a basic understanding of...Read More »
by Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS
CMS is signaling a clear shift in how it views risk adjustment, quality performance, and documentation integrity (CMS, 2024a; CMS, 2025). While recent Medicare Advantage rulemaking stopped short of announcing a new risk...Read More »
