Clinical validation and the role of the CDI professional

July 10, 2017
White Papers
ACDIS Guidance, Clinical & Coding

This paper discusses the concept of clinical validation as it has evolved through CMS regulations and coding guidance. It also attempts to establish consensus about how CDI professionals should incorporate clinical validation into their practice.

Q&A: Coding pneumonia with dyspnea

July 6, 2017
CDI Strategies - Volume 11, Issue 30
Ask ACDIS, Clinical & Coding

Q: If the principal diagnosis is pneumonia, do I need to also code the symptom dyspnea...Read More »

News: CMS finalizes ICD-10-PCS codes for 2018

July 6, 2017
CDI Strategies - Volume 11, Issue 30
Clinical & Coding, News

CMS introduced 3,562 new ICD-10-PCS codes, 1,821 revised titles, and deleted 646 codes. These changes amount to a total of 78,705 codes in the...Read More »

Q&A: Missing documentation for acute kidney injury

July 6, 2017
CDI Blog - Volume 10, Issue 91
Ask ACDIS, Clinical & Coding

Q: We are currently coding a chart for an acute kidney injury which has the baseline serum creatinine and urine output missing from the...Read More »

Coding Clinic for CDI: New advice for neurology, stroke, heart attacks, and drug dependence

July 1, 2017
CDI Journal - Volume 11, Issue 4
ACDIS Guidance, Clinical & Coding

by Sharme Brodie, RN, CCDS
One thing many new CDI specialists hear—and many experienced CDI specialists attest to—is that the CDI...Read More »

Q&A: Choosing a principal diagnosis between anemia and malignancy

June 29, 2017
CDI Strategies - Volume 11, Issue 29
Ask ACDIS, Clinical & Coding

Q: If a patient is admitted for anemia related to a malignancy and is treated only for...Read More »

TBT: Primary, principal, and secondary diagnoses

June 29, 2017
CDI Blog - Volume 10, Issue 87
Ask ACDIS, Clinical & Coding

Q: Sometimes I confuse the secondary diagnosis for the primary diagnosis. Do you have any tips for me to help me discern...Read More »

News: July OPPS update brings changes to ophthalmologic, maternal care codes

June 22, 2017
CDI Strategies - Volume 11, Issue 28
Clinical & Coding, News, Outpatient CDI, Quality & Regulatory

CMS released a change...Read More »

Guest Post: Addressing unspecified codes

June 20, 2017
CDI Blog - Volume 10, Issue 81
ACDIS Guidance, Clinical & Coding

By Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

When CMS told the American Medical Association (AMA) physicians could have a...Read More »

Q&A: Reporting plural effusion with congestive heart failure

June 15, 2017
CDI Strategies - Volume 11, Issue 27
Ask ACDIS, Clinical & Coding

Q: At my institution, we typically do not capture the pleural effusions noted and...Read More »

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