A number of inpatient prospective payment system changes in recent years, due primarily to the Affordable Care Act, have allowed CMS to adjust healthcare reimbursement based on quality metrics and data. But some providers are unaware that many quality scores for themselves and hospitals are...Read More »
In its 2013 position paper, “Electronic Health Records and the Role of the CDI Specialist,” members of the ACDIS Advisory Board addressed several concerns related to challenges and opportunities emerging with the advent of electronic systems. Among them were how to handle copy-and-paste concerns...Read More »
Okemena Ewoterai used to take a folder off a shelf and peer through the papers inside looking for hints—scraps of stories that could lead her to a better understanding of why a particular patient needed to be in her hospital. When she found them, Ewoterai would pull out a piece...Read More »
Queries are definitely not what they used to be. When I first started as a CDI specialist, back when dinosaurs roamed the earth, the query process was a muddy exercise in creative writing.Read More »
By Marion Kruse, BSN, RN, MBA, and Jennifer Cavagnac, CCDS
Every CDI program should objectively evaluate the outcomes, processes, and compliance of their CDI efforts. Auditing and monitoring provides oversight for the CDI program, insight into physician documentation and...Read More »
By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS
At the 2017 ACDIS conference in May, Nelly Leon Chisen, RHIA, director of coding and classification, the executive editor of the American Hospital Association’s (AHA) Coding Clinic ...Read More »
By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS
The 2017 Official Guidelines for Coding and Reporting, effective October 1, 2016, contained a new, perplexing, and problematic section I.A.19 titled “Code Assignment and Clinical Criteria,” which states:...Read More »
