Q: I have a number of questions related to strokes, but essentially, can you describe the clinical definitions of stroke and explain what CDI professionals should be looking for in the medical record?Read More »
Composing and documenting verbal query interactions often confuses CDI specialists. While the guidance published by ACDIS and AHIMA holds for all queries, written and unwritten alike, gauging a verbal query’s compliance can be a tricky business.Read More »
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 »
Outpatient CDI is a different beast than CDI performed in the inpatient hospital setting. The volume of encounters is significantly higher, as is the speed of the visit and the turnover of patients. Trying use the same processes for clarifying documentation with...Read More »
by Paul Evans, RHIA, CCDS, CCS, CCS-P
We have seen our industry grow increasingly complicated each year. With that increased complexity, we also see greater sophistication among our colleagues’ skill levels.
CDI professionals now specialize in quality reviews for hospital–...Read More »
The TRIC tactic to queries provides a quick and systematic approach that ensures the necessary components of the query are present and displayed in a compliant manner to the provider. TRIC is the acronym that stands for these four...Read More »
As the coder or CDI specialist reviews the documentation, he or she will identify opportunities to clarify diagnoses or even to identify conditions that were not previously documented but may be possible given the patient’s presentation.Read More »
Tara Bell, MSN, RN, CCDS, CCM, manager of CDI and utilization review services for UASI based in Cincinnati, will present “Clinical Validation: Expanding Clinical Validation into Outpatient CDI,” on Day 2 of the ACDIS Symposium: Outpatient CDI. Rebecca “Ali” Williams, MSN, RN, CCDS, also...Read More »
