Health Information Management

Don't 'grab and run' with diagnoses

Briefings on Coding Compliance Strategies, August 1, 2008

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If they don’t perform a thorough record review, clinical documentation improvement (CDI) specialists may fail to catch many DRG-changing complications and comorbidities (CC) and major CCs.

Or they may overlook clues that can lead to improved capture of severity of illness. For example, they may miss the opportunity to change a simple pneumonia to a gram-negative pneumonia through a physician query.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Coding Compliance Strategies.

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