If at all possible, CDI programs should review all hospitalizations in a facility for documentation improvement opportunities. And all charts truly means every chart, including every insurance product, regardless of reimbursement mechanism (i.e., by MS-DRG or per diem), including the no-...Read More »
Probably the most onerous duty physicians have is the preparation of the inpatient discharge summary, especially after a long or complicated hospital stay. To be frank, I hate doing discharge summaries. I’ll find every reason to put them off. If I look at the current medical records delinquency...Read More »
The long-anticipated ICD-10-CM Official Guidelines for Coding and Reporting for fiscal year 2017 were released earlier this month, and include a definition for Exclude 1 notes, guidance for meaning and application of the word “with,” and clarification for laterality, according to an...Read More »
The newly proposed Sepsis-3 definition has been the subject of great controversy and consternation since its publication in The Journal of the American Medical Association (JAMA) on February 23, 2016. That controversial definition discarded the concept of SIRS as the basis for defining sepsis...Read More »
There’s no question of the financial sustenance facility case mix index (CMI) provides. An elevated CMI level indicates an increased severity (or acuity weight) in surgical and life sustaining levels of medical care. Facility budgets are formed...Read More »
Those working in the healthcare field really value their credentials. The letters after a person’s name open many professional doors for an individual. When I worked as a nursing manager, if an applicant held AACN certification that simple...Read More »