Clinical validation is definitely a hot topic in CDI right now. According to the 2017 CDI Industry Survey (which will be made available during CDI Week), 85.13% of respondents sent at least one to five clinical validation queries in the last month. Yet, only 41.81% have a policy governing these...Read More »
Is there a best practice when writing a query? ACDIS and AHIMA believe there is, to the point of writing multiple articles and guidelines on the topic. So, what is the “best” way to query a physician and obtain additional information?Read More »
Q: We recently reviewed a troubling case related to sepsis core extractions which revealed that the patient did not have sepsis and the physicians did not document sepsis as there was no bacterial infection. The CDI specialist, however...Read More »
As the role of coded data expands beyond statistical reporting and DRGs to accurate depictions of clinical scenarios, it’s becoming increasingly difficult to determine when a condition reaches a reportable threshold, according to a new ACDIS White Paper “...Read More »
Many facilities employ CDI specialists as frontline educators for physician ICD-10 documentation training. Post-implementation, they rely on CDI staff for continuing education efforts. Any number of continued training tactics may prove successful. One such an approach incorporates documentation...Read More »
Though many coders and auditors say so, there is no official direction that states diagnoses can only be reported if they’re included in the discharge summary. We teach in our CDI Boot Camps that, although it’s desirable if the...Read More »
Those who’ve been in CDI long enough remember the days of colored paper queries slipped into charts. Often, those queries would get lost in the literal shuffle, or simply go unanswered and ignored with no concrete way of tracking the query. Then, electronic health records (EHR) came on the scene...Read More »
