Before starting an ambulatory or outpatient clinical documentation improvement (CDI) program, those tasked with the project must first create some universal definitions, so everyone is on the same page and speaking the same language.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS , explains why physicians may feel that coding and CDI professionals are asking too much and offers potential solutions to ease workplace tensions.
Keeping up with commercial payer requirements can stump any revenue integrity department, and commercial payer audits can be an especially tough puzzle to solve. Review advice from experts on improving internal processes for dealing with commercial audits.
Adriane Martin, DO, FACOS, CCDS , writes about how to accurately capture and report social determinants of health to improve patient outcomes and decrease costs. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
At the beginnings of inpatient coding and CDI, we had books like DRG Expert and Excel-based programs for MS-DRG selections. More than 10 years later, vendors are offering web-based technologies that use artificial intelligence and machine learning to make us even more productive in both coding and CDI. The real question, however, is how we can best leverage those technologies.
Patients who use oxygen at home for a primary respiratory condition typically present with some degree of respiratory failure. Howard Rodenberg, MD, MPH, CCDS , describes common documentation issues related to oxygen requirements for the diagnosis of acute respiratory failure.
Learn how ICD-10-CM coding accuracy, specificity, and compliance impacts provider performance in each of the four performance categories under the Merit-based Incentive Payment System (MIPS). Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Sarah Nehring, CCS, CCDS, says that from the inpatient coding and CDI perspective, sepsis can be one of the trickiest diagnoses. In this article, she reviews 10 things coders wish physicians knew about sepsis documentation and coding.
Many outpatient CDI professionals stepped into their roles blind—not knowing where to begin or how to tell if they were successful. However, as programs mature, they need to be able to track their progress for a number of reasons, including focusing physician education and justifying continued funding from organizational leadership.
A query is a communication tool or process used to clarify documentation in the health record for documentation integrity and accurate code assignment for an individual encounter in any healthcare setting.
