CDI Journal - Volume 5, Issue 2

A CDI program's purpose: Documentation for care quality

April 1, 2011
Quality & Regulatory

by Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI

The overarching goal of a documentation improvement program is not to improve reimbursement for the hospital, but to effect a positive change in the behavior of those who document in the medical record. This change...Read More »
CDI Strategies - Volume 5, Issue 1

Tip: Address inadequate HIPAA Security Rule-required policies and procedures

January 6, 2011
Policies & Procedures, Quality & Regulatory

CMS detailed seven shortcomings, including old and inadequate policies and procedures, in its 2009 audits of healthcare organizations to determine compliance with the HIPAA Security Rule. CMS detailed the findings in its ...Read More »
CDI Journal - Volume 5, Issue 1

Prevent RAC denials: Improve excisional debridement documentation

January 1, 2011
Clinical & Coding, Education, Quality & Regulatory

by Trey La Charité, MD
Every institution reading this column has likely received its first recovery audit contractor (RAC) denials regarding the documentation and coding of excisional debridement procedures (86.22). 

Our hospital is no exception. While we knew that this...Read More »
CDI Blog - Volume 4, Issue 58

Guest Post: A peck of PEPPER, Part 3

November 21, 2011
ACDIS Guidance, Quality & Regulatory

by Linda Renee Brown, RN, MA, CCDS, CCS, CDIP

If you’ve started using your PEPPER to help you identify potential issues at your hospital, good for you!  In this final entry, I’m going to suggest you take it a step further—identifying charts that may fail for lack of medical...Read More »
CDI Blog - Volume 4, Issue 56

Guest Post: A peck of PEPPER, Part 2

November 16, 2011
ACDIS Guidance, Quality & Regulatory

by Linda Renee Brown, RN, MA, CCDS, CCS, CDIP

In my previous entry, I talked about the PEPPER process and how it can be used to help identify potential issues of errors in coding, billing, or medical necessity that are specific to each hospital.  Now I want to review some target...Read More »
CDI Blog - Volume 4, Issue 55

Guest Post: A peck of PEPPER, Part 1

November 9, 2011
ACDIS Guidance, Quality & Regulatory

by Linda Renee Brown, RN, MA, CCDS, CCS, CDIP

My analytical side is always harassing me to get it more involved in what I do. So I decided to dig into our hospital’s PEPPERs. PEPPER is the Program for Evaluating Payment Patterns Electronic Report, issued quarterly. (Calling it a...Read More »
CDI Strategies - Volume 4, Issue 26

News: CMS releases Fact Sheets regarding IPPS, POA, and HAC

December 23, 2010
News, Quality & Regulatory

The Medicare Learning Network released three fact sheets of interest to CDI staff:

  • The “Hospital Acquired Conditions (HAC) in Acute Inpatient Prospective Payment System (IPPS) Hospitals” fact sheet (revised October 2010) is now available in downloadable format at
    • ...Read More »
CDI Strategies - Volume 4, Issue 26

News: Hospital Compare update includes three new inpatient measures

December 23, 2010
News, Quality & Regulatory

The Hospital Compare website, updated on Dec. 11, contains three new inpatient measures. These include Surgical Care Improvement Project (SCIP) Infection 9 (urinary catheter removed on postoperative day one or two) and two new structural measures: participation in a systematic clinical data...Read More »

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