This form contains a proposal for mandatory physician education regarding facility CDI practices. Created by Rebecca "Ali" Williams, RN, BSN, CCDS, this document can be adapted and brought forward to your facility's medical staff director or your program director to foster the ongoing training of incoming physicians.
Christine Lewis, MHA, RHIA, CCS, CCS-P, health information services coding and record processing manager at the Medical University of South Carolina in Charleston, shared this job description, originally printed in Medical Records Briefing, in use at her hospital with those who might be wondering how to structure the position at their own facility.
Hospitals and physicians are transitioning from paper and hybrid medical records to EHRs. Because physicians are also requesting electronic versions of other information, such as newsletters, consider keeping them informed about documentation and coding through the use of e-blasts: mass emails sent to physicians. An e-blast should have a subject line that captures physicians' attention. Beginning with a greeting such as "Dear Dr. _____" is a matter of personal preference. Use these examples of brief e-blast messages pertaining to CDI from HCPro’s CDI Toolkit to create your own messages.
This form highlights the required documentation necessary for common interventional radiology procedures, including catheterizations, imaging guidance, and therapeutic interventions. Stacie L. Buck, RHIA, CCS-P, RCC, CIC, of RadRX.com created this form.
This query form is a request for documentation clarification of HIV Status. It was submitted by Paul Evans, RHIA, CCS, CCS-P, supervisor of clinical documentation integrity at Sutter Health in San Francisco. It was originally posted on the Association of Clinical Documentation Improvement Specialists website.
These documentation examples from Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, show the type of information providers will need to note in order for coders to accurately apply BMI codes in both ICD-9-CM and ICD-10-CM.
When coding guidelines are murky and open for interpretation, coders can sometimes feel as though they're pinned between a rock and a hard place. Discussing the gray areas of coding during a coding roundtable not only helps relieve this tension, but it also helps to establish policies that ensure consistency and continuity. Use this sample charter to build your own coding roundtable.
This form represents one example of a possible request for diagnostic clarification/confirmation of diagnosis donated by Paul Evans, RHIA, CCS, CCS-P, CCDS.
Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director for HCPro, a division of BLR, in Danvers, Massachusetts, and ACDIS Advisory Board member Mark LeBlanc, RN, MBA, CCDS, clinical documentation manager at Hennepin (Missouri) County Medical Center, donated this sample ICD-10-CM burn query.
