While physician documentation drives our CDI and HIM programs, we nevertheless need the assistance of our facility’s nurses and their nursing documentation. Not only are nursing notes and assessments incredibly helpful in formulating...Read More »
I am supervisor of a documentation integrity program at a leading teaching hospital in South Carolina. Our program has been in existence for seven years. I want to reply to the article in the September 2011 edition of Today’s Hospitalist ...Read More »
CDI specialists need to use all the tools available in their documentation training box to effectively change physician behavior. Educational sessions are helpful, particularly when followed by effective queries targeting the same educational issue. Combine this approach with e-mail newsletters...Read More »
MS-DRG 432 (cirrhosis and alcoholic hepatitis with MCC) is one of many MS-DRGs slated for RAC validation audits by HealthDataInsights and Connolly Healthcare, two of the four RACs nationwide.
RACs may target this particular MS-DRG for a variety of reasons, says...Read More »
Just because physicians may document the term excisional debridement it doesn’t mean that coders can automatically code the procedure, said Robert S. Gold, MD, CEO of DCBA, Inc. in Atlanta, during the August 5 audio conference “...Read More »
By Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS
I recently received a fortune cookie from a colleague. After reading the fortune several times, I realized the hidden message certainly has direct relevance to CDI efforts toward affecting overall change in patterns of...Read More »
CMS requires that orders for healthcare services be authenticated using either a handwritten or electronic signature. CMS has made it clear that stamped signatures are not an acceptable form of authentication and previous language in the CMS Program Integrity Manual required a “legible...Read More »
“If you’ve ever read a document that contained convoluted language or gibberish jargon, read on,” a press release from The Center for Plain Language stated. I received that release more than a...Read More »