As the healthcare industry moves to value-based payment programs, the dollars are tighter and the need for collaboration among clinicians, Clinical Documentation Improvement (CDI) specialists, and coders grows
In some respects, the hurdles facing clinical documentation improvement (CDI) program managers/directors mirror those of CDI staff. Like staff, these leaders strive for physician engagement, juggle competing...
As CDI professionals increasingly interrogate the medical record for documentation regarding a host of complicated measures along with DRG assurance, concurrent coding efforts aim to more closely align CDI and coding in real time, allowing each member of the team to...
Like all reporting structures, CMS updates its Hierarchical Condition Category (HCC) list each year. Recently, version 23 was released, and it contains some notable additions that CDI professionals—whether inpatient or outpatient—must be aware of.
ICD-10 codes change every year. So do the rules governing code assignment. Regardless of experience level, taking a closer look at the clinical documentation and indicators needed to qualify a diagnosis as a comorbid condition (CC) or a major CC (MCC) MUST be an annual exercise to ensure that...
Today, improved productivity associated with electronic health records and electronic query systems (e-queries) provide clinical documentation improvement programs the flexibility and supportive data to...
In a world where clinical quality outcomes drive patient care and business practices across the care continuum, complete and accurate clinical documentation is more important than ever before.
Demonstrating positive clinical outcomes requires accurate documentation of the true disease...
Broadening the scope of clinical documentation improvement (CDI) into the outpatient arena has been a growing topic of discussion in recent years. As the overall healthcare industry shifts its focus from volume of services delivered to overall quality of care, the need for complete and accurate...
