Many clinical documentation improvement (CDI) programs now look to capture risk-adjusted conditions which help improve the capture of a patient’s severity of illness and risk of mortality regardless of...Read More »
I remember my first day as a new CDI staff member very well. I had been through an extensive interview process—three interviews, a written test, and a meeting with the consulting...Read More »
Those of us who care for critically ill patients intuitively know who will have a long hospital stay and who will die. As such, intensive care unit (ICU) scoring systems based on clinical indicators such as Acute Physiology and Chronic Health...Read More »
Once you have met the two-year minimum work experience requirement required to sit for the Certified Clinical Documentation Specialist (CCDS) credential exam, it’s time to study. Start by reviewing ...Read More »
Often, the first step in becoming comfortable with the CDI record review process comes from simply shadowing existing CDI staff members. If you are the first and only CDI specialist in your...Read More »
Editor’s note: Barnett is a CDI specialist at MedPartners HIM in Tampa, Florida. She was one of the 12 member 2017 Conference Committee. For more information regarding the conference committee and to apply for...Read More »
Q: What is the best way to document time spent by physicians performing procedures? The CPT® codes state a vague time amount but the doctors struggle with this.
A: Time is always one of those really fun things, especially with E/M codes, because CPT puts a vague...Read More »
