Health Information Management Articles by Topic: Clinical Documentation Improvement
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CDI Strategies, Issue 11, May 16, 2013
This year’s conference features 26 poster presentations on a range of pressing topics...
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CDI Strategies, Issue 11, May 16, 2013
A number of new CDI materials will be available at the HCPro booth (unless noted) throughout the...
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CDI Strategies, Issue 11, May 16, 2013
Editor’s Note: The following tips were adapted from comments by previous ACDIS attendees and...
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CDI Strategies, Issue 11, May 16, 2013
There's a lot to do in Nashville. First and foremost, when you think of Nashville you think of...
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CDI Strategies, Issue 11, May 16, 2013
Editor’s Note: Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, MCP, presents “Integrating CDI...
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CDI Strategies, Issue 11, May 16, 2013
Last week’s ACDIS Quarterly Conference Call hosted 372 participants and featured special...
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CDI Strategies, Issue 11, May 16, 2013
It is hard to believe that the 6th Annual ACDIS Conference is upon us. ACDIS staff will be flying...
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CDI Strategies, Issue 11, May 16, 2013
Can’t make it to the 6th Annual ACDIS conference? Listen in to a series of broadcasts by...
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CDI Strategies, Issue 10, May 9, 2013
Houston, Texas: Harris Health System hosts the next meeting, Thursday, May 9, at 3 p.m. in the...
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CDI Strategies, Issue 10, May 9, 2013
New data released today show significant variation across the country and within communities in...
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CDI Strategies, Issue 10, May 9, 2013
If you are considering expanding your CDI program to include review of pediatric records, consider...
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CDI Strategies, Issue 10, May 9, 2013
ACDIS members are invited to participate in a Quarterly Conference Call taking place today...
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CDI Strategies, Issue 10, May 9, 2013
A number of items have recently been added to the ACDIS Forms & Tools Library. If you have...
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CDI Strategies, Issue 9, April 25, 2013
More than 1,000 CDI professionals now hold the Certified Clinical Documentation Specialist (CCDS...
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CDI Strategies, Issue 9, April 25, 2013
Our next quarterly conference call is scheduled for Thursday, May 9, 1-2 p.m. To access the call...
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CDI Strategies, Issue 9, April 25, 2013
The following ACDIS local chapters have meetings coming up in May and the beginning of June. If you...
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CDI Strategies, Issue 9, April 25, 2013
Here is a statistic that will come as no surprise to most coders and CDI professionals...
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CDI Strategies, Issue 9, April 25, 2013
OptumInsight and ACDIS host a free webinar on June 5, 1-2 p.m., ET, “Technology Innovations...
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CDI Strategies, Issue 9, April 25, 2013
Q: The physician documented mild bronchitis treated with Zithromax in the progress note on day two...
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CDI Strategies, Issue 9, April 25, 2013
Tip: Improve Physician Profiles through SOI/ROM documentation
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CDI Strategies, Issue 8, April 11, 2013
Q: Is it true that a CDI physician advisor/champion cannot be a direct patient care provider?
A...
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CDI Strategies, Issue 8, April 11, 2013
My heart is already warming to thoughts of Nashville in springtime, the site of our 6th annual...
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CDI Strategies, Issue 8, April 11, 2013
The April 2013 edition of the CDI Journal was released last week. It not only includes the latest...
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CDI Strategies, Issue 8, April 11, 2013
There are more than 40 local ACDIS chapters across the country. They range in formality but...
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CDI Strategies, Issue 8, April 11, 2013
Medical necessity for cardiovascular procedures is the top overpayment issue for three out of the...
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CDI Strategies, Issue 8, April 11, 2013
The OIG is taking a closer look at mechanical ventilation, according to its FY 2013 Work Plan. In...
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CDI Strategies, Issue 7, March 28, 2013
Q: How are staffing needs expected to change in relationship to ICD-10?
A: I’m not aware of...
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CDI Strategies, Issue 7, March 28, 2013
The Renaissance Nashville Hotel—site of the ACDIS 6th Annual Conference--has sold out...
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CDI Strategies, Issue 7, March 28, 2013
The following ACDIS local chapters have meetings coming up in April. If you are interested in...
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CDI Strategies, Issue 7, March 28, 2013
The Leapfrog Group. Healthgrades. The Joint Commission. U.S. News and World Report. Consumer...
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CDI Strategies, Issue 7, March 28, 2013
It was hardly explicit that organizations could rebill on an outpatient basis (or fully bill) for...
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CDI Strategies, Issue 7, March 28, 2013
In order to meet the ICD-10 October 1, 2014, implementation timeline, CMS began making necessary...
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CDI Strategies, Issue 7, March 28, 2013
Blue Cross Blue Shield (BCBS) of North Carolina represents the latest payer to join the bundled...
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CDI Strategies, Issue 6, March 14, 2013
The annual paper and pencil seating of the Certified Clinical Documentation Specialist (CCDS) exam...
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CDI Strategies, Issue 6, March 14, 2013
A new platinum-level ACDIS membership package includes a choice of one of two popular audio...
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CDI Strategies, Issue 6, March 14, 2013
In light of the most recent physician query practice guidance released in the February edition of...
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CDI Strategies, Issue 6, March 14, 2013
West Virginia: Meets on Wednesday, March 20, 2 p.m. at Charleston Area Medical Center to discuss...
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CDI Strategies, Issue 6, March 14, 2013
Recovery auditor recoupments increased 14% since 2012, according to the 2013 Recovery Auditor...
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CDI Strategies, Issue 6, March 14, 2013
Rulemaking regarding Stage 3 meaningful use of electronic health records will be delayed until...
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CDI Strategies, Issue 6, March 14, 2013
Q: Our CDI department is developing clarification forms and I have voiced concern with some of the...
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CDI Strategies, Issue 5, February 28, 2013
News: CMS offers ICD-10 Update session
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CDI Strategies, Issue 5, February 28, 2013
Please take a few minutes to participate in this 35-question survey. It asks for input regarding...
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CDI Strategies, Issue 5, February 28, 2013
New guidelines published in the May 2012 Journal of the Academy of Nutrition and Dietetics...
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CDI Strategies, Issue 5, February 28, 2013
Q: Our case-mix index (CMI) seems to be dropping and management is putting pressure on the CDI...
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CDI Strategies, Issue 5, February 28, 2013
The third annual CDI Week takes place on September 16-20, 2013. ACDIS is looking for several...
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CDI Strategies, Issue 5, February 28, 2013
The ACDIS quarterly conference call of Thursday, February 14, is now available for download...
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CDI Strategies, Issue 5, February 28, 2013
During the February conference call, ACDIS unveiled its new “Leadership Toolkit” which...
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CDI Strategies, Issue 4, February 14, 2013
The next quarterly conference call is scheduled for today, Thursday, February 14, 1-2 p.m. ET. To...
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CDI Strategies, Issue 4, February 14, 2013
Recovery Auditors (previously called Recovery Audit Contractors [RAC]) saved Medicare nearly $500...
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CDI Strategies, Issue 4, February 14, 2013
More than 500 organizations have signed on to participate in CMS’ “Bundled Payments for...
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CDI Strategies, Issue 4, February 14, 2013
Q: We recently had a case where the patient was admitted from the ED with pneumonia but the...
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CDI Strategies, Issue 4, February 14, 2013
ACDIS members recently elected four new board members in a popular vote of 10 finalists . (Read...
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CDI Strategies, Issue 4, February 14, 2013
After several months of effort, AHIMA released "Guidelines for Achieving a Compliant Query...
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CDI Strategies, Issue 3, January 31, 2013
When preparing your ICD-10 training schedule, use these questions to develop a baseline:
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CDI Strategies, Issue 3, January 31, 2013
Q: I was under the impression that headings on a query form are leading. Can you help me with...
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CDI Strategies, Issue 3, January 31, 2013
We know many of you rely on ACDIS national benchmarking survey data to compare yourself against...
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CDI Strategies, Issue 3, January 31, 2013
ACDIS will award the CDI Professional of the Year and two winners of Recognition of CDI...
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CDI Strategies, Issue 3, January 31, 2013
On January 15, UnitedHealth Group Inc. and Mayo Clinic announced a new joint venture dubbed Optum...
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CDI Strategies, Issue 2, January 17, 2013
Across the country, 106 new Medicare Shared Savings Program Accountable Care Organizations (ACOs...
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CDI Strategies, Issue 2, January 17, 2013
New York City’s Health and Hospitals Corporation represents the nation’s largest public...
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CDI Strategies, Issue 2, January 17, 2013
This year’s ACDIS Conference takes place May 21–23, 2013 at the Renaissance Nashville...
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CDI Strategies, Issue 2, January 17, 2013
ACDIS Membership update: CDI Journal released
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CDI Strategies, Issue 2, January 17, 2013
Q: Our CDI program is three years old and our administration still questions our productivity...
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CDI Strategies, Issue 2, January 17, 2013
To obtain data regarding CDI program involvement in ICD-10 preparations, ACDIS composed a...
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CDI Strategies, Issue 2, January 17, 2013
New York could become the first state to draft comprehensive measures regarding the identification...
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CDI Strategies, Issue 2, January 17, 2013
New York could become the first state to draft comprehensive measures regarding the identification...
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CDI Strategies, Issue 2, January 17, 2013
Improving patient experience and satisfaction topped the list of healthcare leadership priorities...
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APCs Insider, Issue 1, January 4, 2013
Avoid taking too broad an approach when discussing ICD-10 documentation requirements with...
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CDI Strategies, Issue 1, January 3, 2013
Q: A few times I have seen physicians document Schatzki’s Ring. I understand that if the...
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CDI Strategies, Issue 1, January 3, 2013
“For last year’s words belong to last year’s language. Next year’s words...
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CDI Strategies, Issue 1, January 3, 2013
In the fall, ACDIS Associate Director Melissa Varnavas walked members through a free webinar...
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CDI Strategies, Issue 1, January 3, 2013
A November report from the Government Accountability Office (GAO) calls on CMS to provide better...
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CDI Strategies, Issue 1, January 3, 2013
Depending on how they are sequenced, CC and MCC conditions can have a direct effect on MS-DRG...
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CDI Strategies, Issue 27, December 20, 2012
ICD-10-CM/PCS incorporates laterality, acuity, anatomical specificity, and a slew of additional...
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CDI Strategies, Issue 27, December 20, 2012
Q: Can you clarify the requirements surrounding the use of E codes? We have been working on...
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CDI Strategies, Issue 27, December 20, 2012
When the first ACDIS ICD-10 implementation benchmarking survey published in October of 2010, there...
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CDI Strategies, Issue 27, December 20, 2012
For more than six months, a number of dedicated volunteers have pored over the the ACDIS Forms...
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CDI Strategies, Issue 27, December 20, 2012
The fight over medical necessity continued last week as the American Hospital Association and its...
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CDI Strategies, Issue 26, December 6, 2012
By Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS
In a recent CDI Talk conversation the...
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CDI Strategies, Issue 25, December 6, 2012
Q: A patient with a long history of Type I diabetes is admitted after a syncope episode...
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CDI Strategies, Issue 26, December 6, 2012
The nomination period for the ACDIS advisory board recently closed, and a nomination committee has...
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CDI Strategies, Issue 26, December 6, 2012
ICD-10 Survey: Please take a moment to participate in the 2012 CDI Specialist’s ICD-10...
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CDI Strategies, Issue 26, December 6, 2012
During its November House of Delegates meeting in Honolulu, members of the American Medical...
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CDI Strategies, Issue 26, December 6, 2012
When CMS stopped paying for healthcare-associated infections such as catheter-associated blood...
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CDI Strategies, Issue 26, December 6, 2012
More than $10 million: That’s what Florida-based BayCare Health System agreed to pay the...
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CDI Strategies, Issue 24, November 21, 2012
Earlier this month, CMS released a quick tip sheet “Communicating with your Payers about...
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CDI Strategies, Issue 24, November 21, 2012
ACDIS is pleased to provide one CEU towards recertification of the Certified Clinical Documentation...
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CDI Strategies, Issue 24, November 21, 2012
By Don Butler, RN, BSN
During a recent CDI Talk conversation, I alluded to data available in the...
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CDI Strategies, Issue 23, November 8, 2012
Q: What are the ramifications of leading queries? Who is monitoring whether a query is leading?
A...
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CDI Strategies, Issue 23, November 8, 2012
ACDIS Members Services Specialist Penny Richards is soliciting tips and advice from the ACDIS...
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CDI Strategies, Issue 23, November 8, 2012
The next ACDIS Quarterly Conference Call is scheduled for Thursday, November 15, from 1-2 p.m., ET...
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CDI Strategies, Issue 23, November 8, 2012
ACDIS currently seeks four new members to join its advisory board in 2013. ACDIS advisors are...
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CDI Strategies, Issue 23, November 8, 2012
CDI networking efforts have grown since ACDIS’ inception to nearly 40 local chapters across...
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CDI Strategies, Issue 23, November 8, 2012
On October 16, Representative Sam Graves (R-MO) introduced legislation to reform Recovery...
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CDI Strategies, Issue 23, November 8, 2012
ICD-9 guidelines indicate that coders should not report routine or expected postoperative pain that...
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CDI Strategies, Issue 22, October 25, 2012
Q: I have heard that there is an AHA Coding Clinic for ICD-9-CM, which states that the exacerbation...
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CDI Strategies, Issue 22, October 25, 2012
ACDIS currently seeks four new members to join its advisory board in 2013. ACDIS advisors are...
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CDI Strategies, Issue 22, October 25, 2012
Join ACDIS Associate Director Melissa Varnavas, CPC, on Wednesday, November 7, 1 p.m., ET, for a...
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CDI Strategies, Issue 22, October 25, 2012
A bill, introduced October 16, aims to curtail the proliferation of healthcare audits and medical...
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CDI Strategies, Issue 22, October 25, 2012
Hospitals stand to lose about $1.2 million in annual reimbursement revenue for each 1% drop in its...
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CDI Strategies, Issue 22, October 25, 2012
Getting physicians on board with the transition to ICD-10 won’t be easy, but CMS is trying to...
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CDI Strategies, Issue 22, October 25, 2012
A clear understanding of the definition of principal diagnosis and the factors that play into...
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CDI Strategies, Issue 21, October 11, 2012
CMS recently released the following ICD-10 planning tips in an ICD-10 Industry Email...
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CDI Strategies, Issue 21, October 11, 2012
ACDIS has received several queries regarding networking opportunities for CDI professionals working...
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CDI Strategies, Issue 21, October 11, 2012
Conference Speaker Application Period Closed: More than 130 applications were received. The 2013...
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CDI Strategies, Issue 21, October 11, 2012
Following the close of each fiscal year (FY) quarter, CMS releases statistics for the amount of...
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CDI Strategies, Issue 21, October 11, 2012
Every October, the Office of Inspector General (OIG) releases its Work Plan for the upcoming fiscal...
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CDI Strategies, Issue 21, October 11, 2012
In the recently released 2013 OPPS proposed rule, CMS issued a request for comments that suggests...
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CDI Strategies, Issue 21, October 11, 2012
Although Accountable Care Organizations (ACO) showed an improvement in the quality and performance...
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CDI Strategies, Issue 21, October 11, 2012
During its 84th national convention, AHIMA called for improved governance for health information to...
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JustCoding News: Inpatient, Issue 41, October 10, 2012
The HIM profession is constantly changing, but HIM professionals are still responsible for...
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CDI Strategies, Issue 20, September 27, 2012
When the term ‘sepsis syndrome’ is documented coders and CDI specialists have to query...
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CDI Strategies, Issue 20, September 27, 2012
Since the release of the new ICD-10-CM/PCS implementation date, CMS has been busy publishing a slew...
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CDI Strategies, Issue 20, September 27, 2012
Q: I need further clarification regarding documentation of toxic metabolic encephalopathy...
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CDI Strategies, Issue 20, September 27, 2012
ACDIS is currently seeking speakers to present at the 2013 ACDIS sixth Annual Conference, to be...
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CDI Strategies, Issue 20, September 27, 2012
During the 2nd Annual CDI Week held September 17-21, facilities all over the country celebrated the...
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CDI Strategies, Issue 20, September 27, 2012
In a terse exchange of communication and reports this week, the HHS and American Hospital...
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CDI Strategies, Issue 19, September 13, 2012
The terms “admitting” diagnosis and “principal” diagnosis are not...
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CDI Strategies, Issue 19, September 13, 2012
By Karen Newhouser, RN, BSN, CCM, CCDS
In thinking about all the initiatives swirling around the...
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CDI Strategies, Issue 19, September 13, 2012
Can you provide a novice CDI professional with some tips on where to start with a record...
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CDI Strategies, Issue 19, September 13, 2012
Increasing the adoption of health information technology could help make healthcare delivery more...
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CDI Strategies, Issue 19, September 13, 2012
ACDIS seeks speakers to present at the 2013 ACDIS sixth Annual Conference, to be held May 21-23...
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CDI Strategies, Issue 18, August 30, 2012
National CDI Week celebrations will soon be here. This year’s event takes place September...
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CDI Strategies, Issue 18, August 30, 2012
After months of dedicated effort, The Clinical Documentation Improvement (CDI) Roadmap has been...
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CDI Strategies, Issue 18, August 30, 2012
The ACDIS quarterly conference call of August 16, 2012 is now available for download on the ACDIS...
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CDI Strategies, Issue 18, August 30, 2012
Florida: Reservations for the upcoming Florida ACDIS Chapter meeting slated for Saturday, September...
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CDI Strategies, Issue 18, August 30, 2012
In the recently released 2013 OPPS proposed rule, CMS issued a request for comments that suggests...
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CDI Strategies, Issue 18, August 30, 2012
RAC denials rose by 24% over the previous quarter, according to the August 22 RACTrac survey...
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CDI Strategies, Issue 18, August 30, 2012
Q: I was interested in further discussion about cystic fibrosis coding. I am conducting an audit on...
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CDI Strategies, Issue 18, August 30, 2012
HHS will delay implementation of ICD-10 by one year, from October 1, 2013 to October 1, 2014. HHS...
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HIM-HIPAA Insider, Issue 7, August 20, 2012
Clear and consistent documentation makes a coder’s job much easier, and it improves data...
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CDI Strategies, Issue 17, August 16, 2012
The following ACDIS chapters are just getting off the ground. If you are interested in...
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CDI Strategies, Issue 17, August 16, 2012
A date for the potential ICD-10 implementation deadline may be released soon. The Office of...
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CDI Strategies, Issue 17, August 16, 2012
CMS chose not to include code 428.0 (congestive heart failure, unspecified) as a CC in the IPPS...
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CDI Strategies, Issue 17, August 16, 2012
Q: If a hospital CEO were to tell a new CDI department manager to pull together some...
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CDI Strategies, Issue 17, August 16, 2012
There are now nearly 1,000 professionals who possess the Certified Clinical Documentation...
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CDI Strategies, Issue 16, August 2, 2012
Q: A physician admitted a patient with pneumonia, which was the first listed diagnosis. The...
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CDI Strategies, Issue 16, August 2, 2012
On August 27, CMS launches its Recovery Audit Prepayment Review demonstration project. Over the...
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CDI Strategies, Issue 16, August 2, 2012
The next ACDIS Quarterly Conference Call is scheduled for this Thursday, August 16, from 1-2 p.m...
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CDI Strategies, Issue 16, August 2, 2012
ACDIS local chapters have several meetings scheduled in the coming months. As a reminder if you are...
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CDI Strategies, Issue 16, August 2, 2012
CMS is expected to soon release its final timeline for ICD-10-CM/PCS implementation. Although it...
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CDI Strategies, Issue 16, August 2, 2012
CMS recently redesigned its Hospital Compare website to enhance navigation capabilities for users...
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CDI Strategies, Issue 16, August 2, 2012
A recent Office of the Inspector General report found PacifiCare of Texas received $115 million in...
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CDI Strategies, Issue 16, August 2, 2012
Unplanned readmissions may by overestimated by as much as 25%, according to a study by physicians...
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HIM-HIPAA Insider, Issue 3, July 23, 2012
After hosting the first Clinical Documentation Improvement Week last year, the Association for...
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CDI Strategies, Issue 15, July 19, 2012
Q: We recently had a case where a patient with severe chronic obstructive pulmonary disease...
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CDI Strategies, Issue 15, July 19, 2012
The 2013 ACDIS Annual Conference Committee will help plan and shape next year's conference in...
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JustCoding News: Inpatient, Issue 29, July 18, 2012
New clinical guidelines for malnutrition could help alleviate compliance challenges associated with...
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JustCoding News: Inpatient, Issue 29, July 18, 2012
QUESTION: A patient is admitted with pneumonia and atrial fibrillation and both are present on...
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HIM-HIPAA Insider, Issue 2, July 16, 2012
Q: Our pulmonologists are not comfortable documenting acute respiratory failure unless a patient is...
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HIM-HIPAA Insider, Issue 1, July 9, 2012
Q: Which code should I report for atypical small acinar proliferation of the prostate? Is ICD-9-CM...
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CDI Strategies, Issue 14, July 5, 2012
Q: Our hospital serves a higher than usual population with COPD. Most of these cases are chronic...
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CDI Strategies, Issue 14, July 5, 2012
ACDIS currently has more than 40 local chapters in most states. The following groups are holding...
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CDI Strategies, Issue 14, July 5, 2012
By Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI, CCDS
Broaden the scope of your CDI...
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CDI Strategies, Issue 14, July 5, 2012
Determining when to code a post-surgical complication as opposed to simply considering it to be an...
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CDI Strategies, Issue 14, July 5, 2012
After hosting the first Clinical Documentation Improvement Week last year, ACDIS and the CDI...
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HIM-HIPAA Insider, Issue 27, July 3, 2012
Q: A patient is admitted January 3 and undergoes spinal surgery that day. No laboratory specimens...
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CDI Strategies, Issue 13, June 21, 2012
On June 11, the ACDIS Advisory Board submitted comments to CMS regarding proposed changes to the...
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CDI Strategies, Issue 13, June 21, 2012
The list of approved activities for continuing education units (CEU) applicable for the...
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CDI Strategies, Issue 13, June 21, 2012
CMS recently posted two separate sets of data that provide nationwide statistics on its Recovery...
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CDI Strategies, Issue 13, June 21, 2012
Does your facility mandate physician participation in CDI orientation?
That’s the question...
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CDI Strategies, Issue 13, June 21, 2012
Current SIRS criteria are insufficient, confusing, and don't indicate whether a patient is truly...
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JustCoding News: Inpatient, Issue 25, June 20, 2012
Why do coders need to know about Value Based Purchasing, the Readmissions Reduction Program...
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HIM-HIPAA Insider, Issue 24, June 12, 2012
Q: Our question pertains to the following scenario: The studies section of a history and physical...
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CDI Strategies, Issue 12, June 7, 2012
ACDIS invites you to join a work group to research industry needs and develop best practices for...
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CDI Strategies, Issue 12, June 7, 2012
ACDIS members have access to the Forms & Tools Library which includes:
Query forms...
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CDI Strategies, Issue 12, June 7, 2012
Over a nine-year period, from 2001 to 2010, physicians increased billing of higher level evaluation...
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CDI Strategies, Issue 12, June 7, 2012
Patients of physicians using dictated electronic health records appear to be receiving lower...
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CDI Strategies, Issue 12, June 7, 2012
The latest Program for Evaluating Payment Patterns Electronic Report (PEPPER) was released May 24...
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CDI Strategies, Issue 12, June 7, 2012
US Senator Tom Coburn, MD, (R-OK) suggests Congress hold committee hearings regarding ICD-10...
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CDI Strategies, Issue 12, June 7, 2012
The Office of the Inspector General (OIG) pointed to deficiencies in CMS’ oversight of Zone...
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CDI Strategies, Issue 11, May 24, 2012
Q: Are clinical staff held to the same standard as coders and CDI staff regarding leading questions...
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CDI Strategies, Issue 11, May 24, 2012
By Donald A. Butler, RN
New “variations” on reasons to query physicians was one topic...
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CDI Strategies, Issue 11, May 24, 2012
The next ACDIS Quarterly Conference Call is scheduled for this Thursday, May 24, from 1-2 p.m., ET...
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CDI Strategies, Issue 11, May 24, 2012
The Medicaid RAC program kicked off January 1. Although the program got off to a slow start...
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CDI Strategies, Issue 11, May 24, 2012
After HHS proposed a year-long delay of ICD-10-CM/PCS, questions emerged regarding the current...
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CDI Strategies, Issue 11, May 24, 2012
The May 14 American Hospital Association (AHA) edition of its Audit Education Series: Reducing...
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JustCoding News: Inpatient, Issue 21, May 23, 2012
Many physicians say that systemic inflammatory response syndrome (SIRS) criteria are insufficient...
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HIM-HIPAA Insider, Issue 21, May 22, 2012
Q: Our pulmonologists are not comfortable documenting acute respiratory failure unless the patient...
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CDI Strategies, Issue 10, May 10, 2012
“This claim was denied after review and it was determined that the documentation did not...
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CDI Strategies, Issue 10, May 10, 2012
CMS’ three-day rule defines certain preadmission services as inpatient operating costs...
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CDI Strategies, Issue 10, May 10, 2012
Today marks the official start of the 2012 5th Annual ACDIS Conference. We are so happy to see so...
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CDI Strategies, Issue 10, May 10, 2012
The next Quarterly Conference Call is scheduled for Thursday, May 24, 1-2 p.m., ET. ACDIS members...
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CDI Strategies, Issue 10, May 10, 2012
The American Nurses Association (ANA) and nurses across the country are celebrating National Nurses...
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CDI Strategies, Issue 10, May 10, 2012
The April edition of CMS’ Medicare Quarterly Provider Compliance Newsletterincludes...
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JustCoding News: Inpatient, Issue 19, May 9, 2012
HHS has announced a proposed rule that would postpone ICD-10-CM/PCS implementation from October 1...
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CDI Strategies, Issue 9, April 26, 2012
CMS’ Hospital Compare website now also illustrates how much facilities spend per Medicare...
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CDI Strategies, Issue 9, April 26, 2012
Q: A patient has low rectal cancer. The surgeon performed a robotic lap colon resection. The tissue...
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CDI Strategies, Issue 9, April 26, 2012
CMS projects that payment rates to general acute care hospitals will increase by 2.3% in fiscal...
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CDI Strategies, Issue 9, April 26, 2012
As I’m sure most of you are aware, The Department of Health and Human Services (HHS) has...
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CDI Strategies, Issue 9, April 26, 2012
We have some of the fun events planned for San Diego! If you have any questions, don’t...
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CDI Strategies, Issue 9, April 26, 2012
In the coming year ACDIS plans to complete a revision of its website. Please help us meet your...
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CDI Strategies, Issue 8, April 12, 2012
The HHS proposed delay in ICD-10 implementation may be welcome news for many facilities since...
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CDI Strategies, Issue 8, April 12, 2012
A Maryland hospital allegedly added malnutrition as a secondary diagnosis, employing tactics that...
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CDI Strategies, Issue 3, April 12, 2012
The next two ACDIS Quarterly Conference Calls will be held on Thursday, May 24, from 1-2 p.m., and...
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CDI Strategies, Issue 8, April 12, 2012
The cutoff date for the reduced $199 per night rate at the Manchester Grand Hyatt is Friday, April...
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CDI Strategies, Issue 8, April 12, 2012
Q: If a physician documents “septic shock” should the CDI specialist query for...
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CDI Strategies, Issue 8, April 12, 2012
HHS released a proposed rule Monday, April 9, regarding a potential one-year delay of the...
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CDI Strategies, Issue 8, April 12, 2012
ACDIS is proud to welcome its new CDI Education Director, Cheryl Ericson, MS, RN. In this role...
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CDI Strategies, Issue 8, April 12, 2012
Just because hospitalizations and inpatient admissions due to pneumonia declined from 2003 to 2009...
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CDI Strategies, Issue 7, March 29, 2012
This week marks the 23rd annual AHIMA sponsored Health Information Professionals Week (HIP), themed...
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CDI Strategies, Issue 7, March 29, 2012
ACDIS members have access to a collection of sample Forms & Tools donated by their peers...
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CDI Strategies, Issue 7, March 29, 2012
As of this week, more than 600 CDI-related professionals had registered for the 2012 ACDIS...
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CDI Strategies, Issue 7, March 29, 2012
During a March 7 conference call with payers, CMS indicated that it expects to release information...
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CDI Strategies, Issue 7, March 29, 2012
CMS delayed the HIPAA Version 5010 compliance deadline again last week, giving providers until June...
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CDI Strategies, Issue 7, March 29, 2012
The ICD-9-CM Coordination and Maintenance (C&M) Committee discussed a few changes to the...
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CDI Strategies, Issue 7, March 29, 2012
The Office of the Inspector General (OIG) says CMS incorrectly estimates payment errors in its...
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CDI Strategies, Issue 7, March 29, 2012
CMS posted v29 of the ICD-10 MS-DRGs and an updated version of the v27 Medicare Code Editor (MCE...
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CDI Strategies, Issue 7, March 29, 2012
Q: Can you please help me locate information regarding etiologies of transient ischemic attack...
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JustCoding News: Inpatient, Issue 13, March 28, 2012
These days, documentation improvement and compliance are at the forefront of coders' minds. In some...
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JustCoding News: Inpatient, Issue 13, March 28, 2012
How does medical necessity get “overlooked” on the physician side as well as the...
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HIM-HIPAA Insider, Issue 12, March 20, 2012
Q: A physician admitted a patient with pneumonia, which was the first diagnosis. The second...
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CDI Strategies, Issue 6, March 15, 2012
The Department of Health and Human Services (HHS) recovered nearly $4.1 billion in taxpayer dollars...
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CDI Strategies, Issue 6, March 15, 2012
The Medicare Administrative Contractor (MAC) for J12, which covers Delaware, New Jersey...
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CDI Strategies, Issue 6, March 15, 2012
March is “National Nutrition Month,” according to a recent release from CMS. CDI...
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CDI Strategies, Issue 6, March 15, 2012
Q: We are having a discussion about how to code when the history and physical (H&P), under...
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CDI Strategies, Issue 6, March 15, 2012
The following materials have been posted to the Forms & Tools Library on the ACDIS website...
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CDI Strategies, Issue 6, March 15, 2012
ACDIS formed the CDI Roadmap Committee in September 2011 to help define some of the core...
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CDI Strategies, Issue 6, March 15, 2012
ACDIS welcomes Adelaide M. La Rosa, RN, BSN, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer and...
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CDI Strategies, Issue 6, March 15, 2012
ACDIS thanks the volunteers who have stepped forward to gather CDI professionals in their regions...
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CDI Strategies, Issue 6, March 15, 2012
HHS proposed electronic health record (EHR) systems’ Stage 2 meaningful use requirements in a...
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CDI Strategies, Issue 6, March 15, 2012
After serving as the president of the National Quality Forum (NQF) for more than six years, Janet...
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CDI Strategies, Issue 5, March 1, 2012
What’s in a name? That which we call a rose by any other name would smell as sweet. At least...
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CDI Strategies, Issue 5, March 1, 2012
The 5th Annual ACDIS Conference early registration cutoff date is next Friday, March 9. This year's...
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CDI Strategies, Issue 5, March 1, 2012
The February 16 ACDIS Quarterly Conference Call is now available for download on the ACDIS website...
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CDI Strategies, Issue 5, March 1, 2012
As of Wednesday, February 29, hospitals can access their Value-Based Purchasing Simulated Hospital...
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CDI Strategies, Issue 5, March 1, 2012
The fourth quarter 2011 Short-Term Acute Care Program for Evaluating Payment Patterns Electronic...
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CDI Strategies, Issue 5, March 1, 2012
More than 400 individuals responded to the “2011 Recovery Auditor Benchmarking Survey&rdquo...
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CDI Strategies, Issue 5, March 1, 2012
Review Medicaid Integrity Contractors (MICs) completed 81% of their CMS assignments resulting in...
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JustCoding News: Inpatient, Issue 9, February 29, 2012
Even if you didn’t make a personal New Year's resolution, you should make a professional one...
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JustCoding News: Outpatient, Issue 8, February 22, 2012
Payers are now looking to ensure that physician and facility billing match, which could mean new...
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CDI Strategies, Issue 4, February 16, 2012
Fifty-eight percent of claims billed with MS-DRG 246, percutaneous cardiovascular procedure with...
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CDI Strategies, Issue 4, February 16, 2012
Q: I had a followup question about the Jan. 5, 2012 CDI Strategies article (“Important change...
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CDI Strategies, Issue 4, February 16, 2012
ACDIS recently closed its Facebook “Group” and invited participants in that forum to...
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CDI Strategies, Issue 4, February 16, 2012
CMS’ Recovery Auditors (previously called Recovery Audit Contractors, now associated with the...
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CDI Strategies, Issue 4, February 16, 2012
UnitedHealthcare became the latest private insurer to announce plans to tie its reimbursement to...
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CDI Strategies, Issue 4, February 16, 2012
Central line-associated bloodstream infections (CLABSIs) result in an estimated $700 million in...
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CDI Strategies, Issue 4, February 16, 2012
CMS acting administrator Marilyn Tavenner indicated that the agency could be considering a revision...
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CDI Strategies, Issue 4, February 16, 2012
The ACDIS quarterly conference call is scheduled for today, Thursday, February 16, from 1-2 p.m...
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CDI Strategies, Issue 3, February 2, 2012
ACDIS would like to welcome four new members to the advisory board. These new board members are the...
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CDI Strategies, Issue 3, February 2, 2012
Professional of the year nominee deadline
Click here to download the 2012 award nomination form...
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CDI Strategies, Issue 3, February 2, 2012
Of 165 respondents who took part in a recent website poll, 50 (30%) indicated they earn more than...
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CDI Strategies, Issue 3, February 2, 2012
More than 65% of respondents listed improving physician documentation as “the most important...
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CDI Strategies, Issue 3, February 2, 2012
Transitioning to electronic health records (EHR) is no longer a question of “if” but...
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CDI Strategies, Issue 3, February 2, 2012
Three hours a day. That’s how much time, out of a 12-hour shift, nurses say they spend on...
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CDI Strategies, Issue 3, February 2, 2012
Q: I am fairly new to CDI and I have a nursing background. I’m trying to understand how...
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CDI Strategies, Issue 2, January 19, 2012
Look for special e-mail instructions in the coming week directing ACDIS members to an online voting...
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CDI Strategies, Issue 2, January 19, 2012
Mark your calendars: The first ACDIS quarterly conference call of 2012 has been scheduled for...
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CDI Strategies, Issue 2, January 19, 2012
ACDIS recently updated its website Local Chapter networking page. To connect with Local Chapter...
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CDI Strategies, Issue 2, January 19, 2012
Professional of the Year nominations
It’s time to submit your nominations for the 2012 CDI...
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CDI Strategies, Issue 2, January 19, 2012
CMS recently published a draft ICD-10 MS-DRG definitions. According to the website, the definitions...
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CDI Strategies, Issue 2, January 19, 2012
MLN Matters article SE1121 emphasizes that coders must consider all documentation from licensed...
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CDI Strategies, Issue 2, January 19, 2012
Q:I have a question regarding sequencing. I would usually have sequenced 428.21 (heart failure) as...
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CDI Strategies, Issue 1, January 5, 2012
CMS recently released ICD-10 CC and MCC lists on its web site. It lists the diagnosis by ICD-10...
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CDI Strategies, Issue 1, January 5, 2012
CDI specialists that incorporate quality measures review in their duties take note: The Joint...
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CDI Strategies, Issue 1, January 5, 2012
The 5th annual ACDIS conference, to be held May 10-11, 2012 at the Manchester Grand Hyatt in San...
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CDI Strategies, Issue 1, January 5, 2012
Q:A physician admitted a patient with pneumonia, which was the first diagnosis. The second...
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CDI Strategies, Issue 1, January 5, 2012
If you are a physician advisor, or a CDI department manager looking to add or get the most out of a...
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CDI Strategies, Issue 1, January 5, 2012
The January 2012 CDI Journal has been posted on the ACDIS web site. This edition includes two...
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CDI Strategies, Issue 1, January 5, 2012
There have been a number of additions to the Forms & Tools Library thanks to the donations and...
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CDI Strategies, Issue 27, December 22, 2011
Most of the cases that HIM professionals code are straightforward; some are more difficult, and a...
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CDI Strategies, Issue 27, December 22, 2011
The American Hospital Association (AHA) has not made any formal decisions regarding when it will...
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CDI Strategies, Issue 27, December 22, 2011
The 5th annual ACDIS conference, to be held May 10-11, 2012 at the Manchester Grand Hyatt in San...
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CDI Strategies, Issue 27, December 22, 2011
Effective December 15, Trailblazer Health Enterprises, LLC, began prepay service-specific medical...
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CDI Strategies, Issue 27, December 22, 2011
On December 7, CMS published a final rule in the Federal Register that will give qualified...
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CDI Strategies, Issue 27, December 22, 2011
Q:Does documentation such as “suggestive of” or “suspicious of” qualify as...
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CDI Strategies, Issue 26, December 8, 2011
Hospitals reported syncope and collapse (MS-DRG 312) as the top MS-DRG with respect to financial...
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CDI Strategies, Issue 26, December 8, 2011
Are you planning to take the CCDS exam? If so, please note that we have made some revisions to the...
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CDI Strategies, Issue 26, December 8, 2011
Uninsured patients spend less time in the hospital than insured patients, while Medicare patients...
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CDI Strategies, Issue 26, December 8, 2011
By Jennifer Avery, CCS, CPC, CPC-H, CPC-I
Late effects are considered to be the residual effects...
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CDI Strategies, Issue 26, December 8, 2011
Minnesota
The next meeting of the Minnesota group will be a 3M sponsored event Friday, Dec. 16, 8...
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JustCoding News: Inpatient, Issue 49, December 7, 2011
Clinical documentation plays a vital role in all coding. It is especially important, however, when...
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JustCoding News: Inpatient, Issue 49, December 7, 2011
As the weather cools, the heat is on coders to properly report the high number of pneumonia cases...
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JustCoding News: Inpatient, Issue 49, December 7, 2011
Coders should not underestimate the vital role they play in their organization’s efforts to...
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HIM-HIPAA Insider, Issue 49, December 6, 2011
Q: How should we code arthroscopic patellofemoral resurfacing? Some physicians want to code this as...
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CDI Strategies, Issue 25, December 1, 2011
Invest in computer-assisted coding (CAC) now because of its potential positive impact on...
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CDI Strategies, Issue 25, December 1, 2011
Q:Should present-on-admission (POA) queries stay in the record and become a part of the permanent...
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CDI Strategies, Issue 25, December 1, 2011
The ACDIS Blog offers CDI specialists yet another forum to learn about CDI-related news and...
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CDI Strategies, Issue 25, December 1, 2011
Starting in January 2012, facilities could see pre-payment reviews from auditors involved in a new...
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CDI Strategies, Issue 24, November 10, 2011
A final reminder to our ACDIS membership that our next quarterly conference will take place next...
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CDI Strategies, Issue 24, November 10, 2011
The auditing arm of the Department of Health and Human Services (HHS) plans to crack down on...
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CDI Strategies, Issue 24, November 10, 2011
CMS will host a National Provider Call on Thursday, November 17, 1:30-3 p.m. (ET) regarding ICD-10...
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CDI Strategies, Issue 24, November 10, 2011
On November 1, CMS issued its Medicare Physician Fee Schedule (MPFS) for calendar year 2012. In it...
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CDI Strategies, Issue 24, November 10, 2011
On October 20, CMS released its long-awaited final rule governing accountable care organizations...
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CDI Strategies, Issue 24, November 10, 2011
Coders and CDI specialists need to understand the implications coding and sequencing may have on...
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CDI Strategies, Issue 24, November 10, 2011
Q:Can a patient have encephalopathy after a surgery? For example, a patient post surgery...
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CDI Strategies, Issue 24, November 10, 2011
Thanks to the hard work of a volunteer conference committee, the 2012 ACDIS annual conference...
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CDI Strategies, Issue 24, November 10, 2011
The nomination period for the ACDIS Advisory Board is open through November 25, 2011. ACDIS is...
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HIM-HIPAA Insider, Issue 45, November 8, 2011
Q: One of our podiatrists documents “surgical debridement of devitalized tissue with...
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CDI Strategies, Issue 23, October 27, 2011
Since Emory Healthcare Inc., is a teaching hospital, Bonnie I. Epps, MN, RN, manager of its CDI...
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CDI Strategies, Issue 23, October 27, 2011
Q: I am unsure how “ribs” are categorized in ICD-10. I don’t understand if taking...
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CDI Strategies, Issue 23, October 27, 2011
We are currently seeking four new ACDIS members to join our advisory board in 2012. ACDIS advisors...
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CDI Strategies, Issue 23, October 27, 2011
The next ACDIS membership quarterly conference call is scheduled for Thursday, November 17, from...
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CDI Strategies, Issue 23, October 27, 2011
Patients cared for in facilities which HealthGrades deems as five-star have 73% less risk of dying...
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CDI Strategies, Issue 23, October 27, 2011
CMS recently updated its Medicare Severity (MS) Grouper with Medicare Code Editor (MCE) ICD-10 R1...
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CDI Strategies, Issue 23, October 27, 2011
The Department of Health and Human Services and the Department of Defense accused Baltimore-based...
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HIM-HIPAA Insider, Issue 42, October 18, 2011
In the November issue of MRB, you’ll find articles on the following topics!
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CDI Strategies, Issue 22, October 13, 2011
We’re in the final stages of choosing speakers and sessions for the 5th Annual ACDIS National...
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CDI Strategies, Issue 22, October 13, 2011
The October edition of the CDI Journal has been posted. This issue includes:
ACDIS Director...
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CDI Strategies, Issue 22, October 13, 2011
By Jennifer Avery, CCS, CPC, CPC-H, CPC-I
As an AHIMA ICD-10 certified trainer, I have been doing...
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CDI Strategies, Issue 22, October 13, 2011
Based on overall satisfaction, CMS contractors received a mean score of 3.77 out of a maximum...
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CDI Strategies, Issue 20, September 29, 2011
The 83rd AHIMA Convention and Exhibit takes place in a few days and ACDIS is proud to support the...
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CDI Strategies, Issue 20, September 29, 2011
Thanks to all the CDI and related healthcare professionals who helped make the first annual CDI...
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CDI Strategies, Issue 20, September 29, 2011
On September 14, CMS released its Medicaid recovery audit contractor (RAC) final rule, which sets...
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CDI Strategies, Issue 20, September 29, 2011
Documentation improvement staff often struggle with principal diagnosis selection. A clear...
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CDI Strategies, Issue 20, September 29, 2011
The quarterly reports issued by the Program for Evaluating Payment Patterns Electronic Report...
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CDI Strategies, Issue 20, September 29, 2011
Q: How should I query for systemic inflammatory response syndrome (SIRS) if SIRS codes...
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HIM-HIPAA Insider, Issue 38, September 20, 2011
The first ever Clinical Documentation Improvement Week is being held this week, Sept. 18–24...
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CDI Strategies, Issue 18, September 15, 2011
Well, we’re almost here at Clinical Documentation Improvement Week, which begins this Sunday...
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CDI Strategies, Issue 18, September 15, 2011
ACDIS members can read about the highlights from this year’s conference, learn about the CDI...
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CDI Strategies, Issue 18, September 15, 2011
The deadline to submit speaker applications for the 5th annual ACDIS conference (May 10-11, 2012...
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CDI Strategies, Issue 18, September 15, 2011
CMS updated its Recovery Audit Contractor Statement of Work (SOW), according to an article in AHA...
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CDI Strategies, Issue 18, September 15, 2011
Being described as "worse" in a CMS HospitalCompare data file is a dubious...
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CDI Strategies, Issue 18, September 15, 2011
If you’re looking for an easy, inexpensive way to celebrate the first annual Clinical...
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CDI Strategies, Issue 18, September 15, 2011
Q: Some of our physicians are uncomfortable making addendums to the discharge summary to include...
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CDI Strategies, Issue 18, September 2, 2011
To make up a gap in expected overpayment collections Recovery Audit Contractors may escalate audit...
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CDI Strategies, Issue 18, September 2, 2011
“CMS faces challenges incorporating resource use and quality measures for physician feedback...
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CDI Strategies, Issue 18, September 2, 2011
AHIMA secured a “prestigious” role in the ongoing development of electronic healthcare...
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CDI Strategies, Issue 18, September 2, 2011
In less than a month ACDIS kicks off the first ever Clinical Documentation Improvement Week...
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CDI Strategies, Issue 18, September 2, 2011
Trying to convince physicians that good documentation has “something in it for them” is...
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CDI Strategies, Issue 18, September 2, 2011
$8.9 million. That is the amount Kentucky-based Baptist Healthcare Systems, Inc., had to pay as of...
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CDI Strategies, Issue 18, September 2, 2011
Out of 88 claims for MS-DRG 246 (percutaneous cardiovascular procedure with drug-eluting stent with...
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HIM-HIPAA Insider, Issue 35, August 30, 2011
As coders sharpen their knowledge of anatomy and physiology and hone their ICD-10-CM/PCS skills...
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CDI Strategies, Issue 17, August 18, 2011
Conference call
The next quarterly conference call for ACDIS members is scheduled for Thursday...
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CDI Strategies, Issue 17, August 18, 2011
The ACDIS e-learning library allows members the ability to keep up to date on the latest issues and...
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CDI Strategies, Issue 17, August 18, 2011
In January facilities should expect to receive Recovery Audit Contractors (RAC) demand letters not...
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CDI Strategies, Issue 17, August 18, 2011
CMS recently updated Hospital Compare web site data for 30-day mortality rates and 30-day...
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CDI Strategies, Issue 17, August 18, 2011
It started with two courageous coders who knew the query process where they worked at Johns Hopkins...
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CDI Strategies, Issue 17, August 18, 2011
By Linda Renee Brown, RN, CCRN, CCDS, MA
One of the most confusing diagnoses to code and sequence...
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CDI Strategies, Issue 17, August 18, 2011
Q: Should queries from different departments be treated and stored differently? Should they be...
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HIM-HIPAA Insider, Issue 33, August 16, 2011
It started with two courageous coders who knew the query process at Johns Hopkins Bayview Medical...
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CDI Strategies, Issue 16, August 4, 2011
Much discussion has been held of late regarding the creation of Accountable Care Organizations...
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CDI Strategies, Issue 16, August 4, 2011
Healthcare providers in the A/B MAC jurisdiction 1 have a problem—a paid claims error rate...
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CDI Strategies, Issue 16, August 4, 2011
Q: I am having trouble grasping the concept of “marrying” DRGs. Can you explain what...
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CDI Strategies, Issue 16, August 4, 2011
The next quarterly conference call for ACDIS members is scheduled for Thursday, August 18, from 1-2...
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CDI Strategies, Issue 16, August 4, 2011
JA Thomas expanded its CDI offerings to include the ED and other points of entry roughly two years...
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CDI Strategies, Issue 16, August 4, 2011
We are currently seeking speakers to present at the 2012 ACDIS fifth Annual Conference, to be held...
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CDI Strategies, Issue 16, August 4, 2011
CMS released the Inpatient Prospective Payment System (IPPS) Final Rule, Monday, Aug. 1, reducing a...
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CDI Strategies, Issue 16, August 4, 2011
CMS recently released its July edition of the Medicare Quarterly Provider Compliance Newsletter but...
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CDI Strategies, Issue 15, July 21, 2011
Q: Recently I have discussed the BMI and malnutrition status on patients with our Registered...
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CDI Strategies, Issue 15, July 21, 2011
The latest group of recipients of the CCDS credential met the requirements for the CCDS...
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CDI Strategies, Issue 15, July 21, 2011
ACDIS is sponsoring the industry’s first Clinical Documentation Improvement Week on Sept...
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CDI Strategies, Issue 15, July 21, 2011
RACs can easily data-mine for noncompliance related to coding for ventilator support, says Glenn...
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CDI Strategies, Issue 15, July 21, 2011
ICD-10-PCS codes include one digit for the root operation that the provider performs. The root...
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CDI Strategies, Issue 15, July 21, 2011
Each month the Revenue Cycle Institute publishes a free sample tool or form for readers. This...
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CDI Strategies, Issue 14, July 7, 2011
CDI Journal is a quarterly publication featuring in-depth articles regarding current...
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CDI Strategies, Issue 14, July 7, 2011
Inpatient hospital claims submitted to Medicare contain “a significant amount” of...
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CDI Strategies, Issue 14, July 7, 2011
Evaluation and Management (E/M) services accounted for $28 billion in Part B payments nationally...
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CDI Strategies, Issue 14, July 7, 2011
Many cases exist in which CDI specialists need to query physicians to clarify the use of the term...
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CDI Strategies, Issue 14, July 7, 2011
I previously started a conversation on CDI Talk entitled “Failed Programs,” hoping...
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CDI Strategies, Issue 14, July 7, 2011
Q: I have been trying to determine whether a skin graft includes debridement. Based on what I...
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CDI Strategies, Issue 0, June 24, 2011
Date of Request: June 24, 2011
Job Title: SR. SPECIALIST, CLINICAL DOCUMENTATION IMPROVEMENT
Name...
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CDI Strategies, Issue 13, June 23, 2011
ACDIS is pleased to announce the availability of continuing education (CE) credits linked to its...
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CDI Strategies, Issue 13, June 23, 2011
ACDIS submitted comments to CMS regarding recent updates to the ICD-9-CM codes not included in the...
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CDI Strategies, Issue 13, June 23, 2011
In 2002 the National Quality Forum (NQF) created its report Serious Reportable Events in...
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CDI Strategies, Issue 13, June 23, 2011
J.A. Thomas and Associates (JATA) says nearly a quarter of healthcare facilities are not...
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CDI Strategies, Issue 13, June 23, 2011
While the bulk of discussion regarding how to ethically and responsibly submit queries to...
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CDI Strategies, Issue 13, June 23, 2011
Q: Is there are industry standard for physician query response rate expectations? Our...
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HIM-HIPAA Insider, Issue 24, June 14, 2011
CMS has released its fiscal year (FY) 2012 IPPS proposed rule, and coders need to note various...
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CDI Strategies, Issue 12, June 9, 2011
Note: Due to a large volume of applications received, the application period is now closed.
Our...
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CDI Strategies, Issue 12, June 9, 2011
CMS released a new proposed rule on June 3 which aims to “give consumers and employers better...
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CDI Strategies, Issue 12, June 9, 2011
More than 300 ACDIS members dialed into the Quarterly Conference Call on Thursday, May 26 to learn...
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CDI Strategies, Issue 12, June 9, 2011
Provider-preventable conditions (PPC), including health care-acquired conditions (HCAC), are now...
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CDI Strategies, Issue 12, June 9, 2011
CMS published the 2012 Inpatient Prospective Payment System (IPPS) proposed rule May 5 in the...
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CDI Strategies, Issue 12, June 9, 2011
On Thursday, May 26, the Department of Health and Human Services (HHS) announced its plans to...
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CDI Strategies, Issue 12, June 9, 2011
Q: With all the auditing going on I would like to find out how effects CDI programs in other...
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HIM-HIPAA Insider, Issue 23, June 7, 2011
Coders should be mindful of the words they choose when drafting physician queries. Certain...
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CDI Strategies, Issue 11, May 26, 2011
New job postings http://www.hcpro.com/acdis/jobs.cfm
New forms and tools (see Physician...
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CDI Strategies, Issue 11, May 26, 2011
2024. Thirteen years. That’s how long Medicare’s trust fund is expected to last...
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CDI Strategies, Issue 11, May 26, 2011
“Publicly marketed hospital rating systems of surgical quality such as the US News &...
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CDI Strategies, Issue 11, May 26, 2011
Recovery Audit Contractors (RAC) reported doubled its recovery amounts since last...
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CDI Strategies, Issue 11, May 26, 2011
Legible. Complete. Dated, timed, signed, and authenticated. That's what section 482.24 of the...
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CDI Strategies, Issue 11, May 26, 2011
Q:: What does ‘pre-bill retrospective physician query process’ mean?
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CDI Strategies, Issue 10, May 12, 2011
It seems to be hard to believe, but we’re approaching the two-year anniversary of the launch...
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CDI Strategies, Issue 10, May 12, 2011
What kind of return can your CDI program guarantee in terms of RAC preparedness? That’s the...
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CDI Strategies, Issue 10, May 12, 2011
A mandate of the Affordable Care Act, CMS’ value-based purchasing (VBP) program will begin in...
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CDI Strategies, Issue 10, May 12, 2011
Nearly 500 healthcare quality professionals indicated that staffing shortages could be the biggest...
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CDI Strategies, Issue 10, May 12, 2011
Improper coding of MS-DRG 813 (coagulation disorders), reporting an extensive operating room...
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CDI Strategies, Issue 10, May 12, 2011
Hospitals can start experimenting with how new ICD-10-CM/PCS codes will translate to MS-DRGs since...
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CDI Strategies, Issue 10, May 12, 2011
Q:I’ve heard different opinions between the coders and some of our CDI consultants regarding...
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CDI Strategies, Issue 9, April 28, 2011
The 2010 CDI Specialist’s Salary Survey and the 2010 Physician Queries Benchmarking Report...
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CDI Strategies, Issue 9, April 28, 2011
CMS expects a year-over-year reduction of 0.5% in payments to acute care hospitals under the...
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CDI Strategies, Issue 9, April 28, 2011
In response to President Barack Obama’s January 18 executive order aimed at reducing federal...
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CDI Strategies, Issue 9, April 28, 2011
By Donald A. Butler, RN, BSN
The more I learn about ICD-10, the more worried I get. At this...
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CDI Strategies, Issue 9, April 28, 2011
Q: What is the recommended ratio for CDI professionals regarding the number of patients and...
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HIM-HIPAA Insider, Issue 16, April 19, 2011
The Association of Clinical Documentation Improvement Specialists (ACDIS) submitted comments March...
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CDI Strategies, Issue 8, April 14, 2011
Last week more than 700 CDI professionals attended the 4th Annual ACDIS Conference at the Hilton...
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CDI Strategies, Issue 8, April 14, 2011
The April edition of the CDI Journal was posted last week, and is available to ACDIS members for...
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CDI Strategies, Issue 8, April 14, 2011
Hospital acquired conditions (HAC): The phrase seems simple enough to understand. These are...
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CDI Strategies, Issue 8, April 14, 2011
The Centers for Disease Control (CDC) in March posted new 2011 guidelines for ICD-10-CM. There are...
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CDI Strategies, Issue 8, April 14, 2011
Legible. Complete. Dated, timed, signed, and authenticated. That's what section 482.24 of the...
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CDI Strategies, Issue 8, April 14, 2011
Q: What does ‘pre-bill retrospective physician query process’ mean?
A:A pre-bill...
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HIM-HIPAA Insider, Issue 14, April 5, 2011
Physician queries are a predictable part of any coder's job. Coders may pose hundreds—even...
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CDI Strategies, Issue 7, March 31, 2011
Members of the Association of Clinical Documentation Improvement Specialists (ACDIS) advisory board...
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CDI Strategies, Issue 7, March 31, 2011
We are very excited about the Fourth Annual ACDIS Conference next week (April 7-8, Orlando FL) and...
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CDI Strategies, Issue 7, March 31, 2011
By Vickie Balistreri, BA, RHIA, CCS, CCS-P, CCDS, CPC, CPC-H
“Tell me and I’ll...
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CDI Strategies, Issue 6, March 17, 2011
A patient’s medical record could include a laundry list of diagnoses, but not all of these...
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CDI Strategies, Issue 6, March 17, 2011
Q:I know that in an inpatient setting coders are allowed to use suspected diagnosis when a...
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CDI Strategies, Issue 6, March 17, 2011
by Steven Robinson, MS, PA-O, RN, CPUR
What are the most important factors that measure success...
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CDI Strategies, Issue 5, March 3, 2011
Nearly 550 CDI professionals have registered to attend the 4th Annual ACDIS Conference in Orlando...
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CDI Strategies, Issue 5, March 3, 2011
A number of ACDIS members will be eligible for Certified Clinical Documentation Specialist...
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CDI Strategies, Issue 5, March 3, 2011
By Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI
The Fourth Quarter PEPPER reports...
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CDI Strategies, Issue 5, March 3, 2011
The Department of Health and Human Services (HHS) called it the largest healthcare fraud sting in...
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CDI Strategies, Issue 5, March 3, 2011
If the data is true, the population of a couple of concentrated areas in California suffer from...
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CDI Strategies, Issue 5, March 3, 2011
Q: AHIMA’s 2008 practice brief, “Managing an Effective Query Process,” appears to...
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CDI Strategies, Issue 5, March 3, 2011
by Steven Robinson, MS, PA-O, RN, CPUR
What are the most important factors that measure success...
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CDI Strategies, Issue 4, February 17, 2011
ACDIS conducts a new poll of its members nearly every week. Members can submit their responses and...
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CDI Strategies, Issue 4, February 17, 2011
by Steven Robinson, MS, PA-O, RN, CPUR
What are the most important factors that measure success...
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CDI Strategies, Issue 4, February 17, 2011
Q:
Since Acute Renal Failure (ARF) is no longer a MCC (as of October 1, 2010). I would like...
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CDI Strategies, Issue 4, February 17, 2011
The RACs have ramped up medical necessity reviews. Determining the medical necessity of an...
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CDI Strategies, Issue 4, February 17, 2011
CMS released a number of helpful ICD-10 items recently including:
The written transcript and...
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CDI Strategies, Issue 4, February 17, 2011
A recent special edition MedLearn Matters article SE1028 outlines four risk areas targeted by the...
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CDI Strategies, Issue 4, February 17, 2011
The next quarterly conference call for ACDIS members will be held on Thursday, February 24, 1-2...
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CDI Strategies, Issue 3, February 3, 2011
ACDIS is pleased to announce the election of four new advisory board members, terms of service...
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CDI Strategies, Issue 3, February 3, 2011
A number of new tools and presentations have been posted to the ACDIS Forms & Tools Library...
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CDI Strategies, Issue 3, February 3, 2011
Despite the guidance CMS offers about proper inpatient admission decisions, hospitals still...
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CDI Strategies, Issue 3, February 3, 2011
As announced in the January 20 issue of CDI Strategies, CMS issued a proposed rule to establish a...
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CDI Strategies, Issue 3, February 3, 2011
In a recent National Health Expenditure Accounts (NHEA) report, the group indicated that U.S...
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CDI Strategies, Issue 3, February 3, 2011
Q: Our small hospital has decided at this time that they no longer need the services of a Physician...
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CDI Strategies, Issue 3, February 3, 2011
by Steven Robinson, MS, PA-O, RN, CPUR
What are the most important factors that measure success...
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Briefings on Coding Compliance Strategies, Issue 2, February 1, 2011
Learn about reporting secondary diagnoses, assigning the POA indicator, ICD-10 procedure...
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CDI Strategies, Issue 2, January 20, 2011
The January 2011 edition of the CDI Journal is available for ACDIS members on the association...
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CDI Strategies, Issue 2, January 20, 2011
At the start of the New Year, CMS released an enhanced Physician Compare site which “begins...
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CDI Strategies, Issue 2, January 20, 2011
by Steven Robinson, MS, PA-O, RN, CPUR
What are the most important factors that measure success...
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CDI Strategies, Issue 1, January 6, 2011
Hurry; early bird discount expires on Feb. 4
Although we’re all getting back from the...
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CDI Strategies, Issue 1, January 6, 2011
In 2008, a total of 132 individuals completed ACDIS’ CDI specialists’ salary survey. In...
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CDI Strategies, Issue 1, January 6, 2011
The transition from ICD-9-CM Volume 3 procedure codes to ICD-10-PCS will be by all accounts a...
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CDI Strategies, Issue 1, January 6, 2011
CMS detailed seven shortcomings, including old and inadequate policies and procedures, in its 2009...
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CDI Strategies, Issue 1, January 6, 2011
According to the 2010 Physician Query Benchmarking Report (to be released later this month) 54% of...
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CDI Strategies, Issue 1, January 6, 2011
Q: How should providers prepare for Medicaid RACs?
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CDI Strategies, Issue 1, January 6, 2011
by Steven Robinson, MS, PA-O, RN, CPUR
The DRG system, implemented nationally in 1983, was...
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HIM-HIPAA Insider, Issue 51, December 28, 2010
As the Patient Protection and Affordable Care Act implementation progresses, the quality and...
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CDI Strategies, Issue 26, December 23, 2010
The nomination period for the 2011 CDI Professional of the Year award is open through January...
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CDI Strategies, Issue 26, December 23, 2010
In 2008, a total of 132 individuals completed ACDIS’ CDI specialists’ salary survey. In...
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CDI Strategies, Issue 26, December 23, 2010
The Medicare Learning Network released three fact sheets of interest to CDI staff:
The...
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CDI Strategies, Issue 26, December 23, 2010
The RAC program was fully under way in 2010, and providers continue to struggle with it as the year...
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CDI Strategies, Issue 26, December 23, 2010
The Hospital Compare website, updated on Dec. 11, contains three new inpatient measures. These...
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CDI Strategies, Issue 26, December 23, 2010
by Donald A. Butler, RN, CCDS
One analysis I particularly like is a metric I refer to as chart...
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CDI Strategies, Issue 26, December 23, 2010
by Steven Robinson, MS, PA-O, RN, CPUR
The DRG system, implemented nationally in...
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CDI Strategies, Issue 25, December 9, 2010
The National Quality Forum (NQF) published a draft report updating the NQF-endorsed Serious...
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CDI Strategies, Issue 25, December 9, 2010
The Medicare Payment Advisory Commission (MedPAC) considered a draft recommendation from its chair...
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CDI Strategies, Issue 25, December 9, 2010
The Department of Justice (DOJ) recovered $2.5 billion in healthcare fraud recoveries for fiscal...
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CDI Strategies, Issue 25, December 9, 2010
CMS sought comments from healthcare providers regarding proposed implementation of accountable care...
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CDI Strategies, Issue 25, December 9, 2010
The Commission on Certification for Health Informatics and Information Management (CCHIIM) recently...
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CDI Strategies, Issue 25, December 9, 2010
Editor’s note: ACDIS recently published Coding Clinic update, a review of the most recent...
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CDI Strategies, Issue 25, December 9, 2010
by Steven Robinson, MS, PA-O, RN, CPUR
The DRG system, implemented nationally in 1983, was...
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Briefings on Coding Compliance Strategies, Issue 12, December 1, 2010
Learn about the OIG work plan, acute kidney injursy, acute kidney failure, documentation and DNFB...
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CDI Strategies, Issue 24, November 24, 2010
CMS has modified the additional documentation request (ADR) limits (i.e., medical record request...
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CDI Strategies, Issue 24, November 24, 2010
A recent ACDIS poll asked “which type of professional comprises the majority of your CDI...
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CDI Strategies, Issue 23, November 11, 2010
ACDIS Work Group members spent considerable energy creating the 2010 Physician Query Benchmarking...
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CDI Strategies, Issue 23, November 11, 2010
CMS released the long-anticipated proposed rule for Medicaid recovery audit contractors (RACs...
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CDI Strategies, Issue 23, November 11, 2010
On October 14, we reported that CMS issued a controversial MLN Matters special edition (SE) article...
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CDI Strategies, Issue 23, November 11, 2010
In the spring, AHIMA released its “Guidance for Clinical Documentation Improvement...
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CDI Strategies, Issue 23, November 11, 2010
CDI specialists need to use all the tools available in their documentation training box to...
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CDI Strategies, Issue 23, November 11, 2010
The following items have been updated on the ACDIS website:
2011 ICD-9-CM codes...
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CDI Strategies, Issue 23, November 11, 2010
by Steven Robinson, MS, PA-O, RN, CPUR
The DRG system, implemented nationally in 1983, was...
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HIM-HIPAA Insider, Issue 43, November 2, 2010
Three years. That’s how long you have to prepare for the implementation of the International...
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Briefings on Coding Compliance Strategies, Issue 11, November 1, 2010
Learn about medical necessity audits, linking signs and symptoms with definitive conditions...
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CDI Strategies, Issue 22, October 28, 2010
At the September 15, 2010 ICD-9-CM Coordination & Maintenance Committee Meeting, the committee...
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CDI Strategies, Issue 22, October 28, 2010
Patients who survive sepsis infections face a long battle with cognitive and physical decline...
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CDI Strategies, Issue 22, October 28, 2010
MS-DRG 432 (cirrhosis and alcoholic hepatitis with MCC) is one of many MS-DRGs slated for RAC...
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CDI Strategies, Issue 22, October 28, 2010
by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS
The release of CMS Medlearn Matters articles...
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CDI Strategies, Issue 22, October 28, 2010
Q: Recently, a consultant suggested that if we asked the physician to clarify systolic/diastolic on...
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CDI Strategies, Issue 22, October 28, 2010
by Steven Robinson, MS, PA-O, RN, CPUR
The DRG system, implemented nationally in 1983, was...
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CDI Strategies, Issue 21, October 14, 2010
The latest edition of the CDI Journal published October 1 and is now posted to the ACDIS website...
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CDI Strategies, Issue 21, October 14, 2010
A recent MLN Matters article has changed the official coding guidelines to define what...
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CDI Strategies, Issue 21, October 14, 2010
Kaiser Permanente recently donated its electronic database of medical terminology to the National...
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CDI Strategies, Issue 21, October 14, 2010
When it comes to tracking CDI program data, many facilities fall back on the information provided...
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CDI Strategies, Issue 21, October 14, 2010
by Shannon McCall, RHIA, CCS, CCS-P, CPC-I, CCDS
I often wondered how the ICD-9-CM code set would...
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CDI Strategies, Issue 21, October 14, 2010
by Steven Robinson, MS, PA-O, RN, CPUR
The DRG system, implemented nationally in 1983, was the...
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CDI Strategies, Issue 20, September 30, 2010
Just because physicians may document the term excisional debridement it doesn’t mean that...
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CDI Strategies, Issue 20, September 30, 2010
Realizing that the go-live date won’t change, some facilities already have organization-wide...
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CDI Strategies, Issue 20, September 30, 2010
By Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS
I recently received a fortune cookie from a...
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CDI Strategies, Issue 20, September 30, 2010
Q: Whenever we get a trauma patient, it’s either very easy to get to the multiple significant...
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CDI Strategies, Issue 20, September 30, 2010
by Steven Robinson, RN
Most physicians want to provide an accurate written picture of their...
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HIM-HIPAA Insider, Issue 38, September 28, 2010
Did you know that HCPro Revenue Cycle Institute offers free white papers on a variety of coding and...
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CDI Strategies, Issue 19, September 16, 2010
Recent approval of a RAC issue for inpatient hospital claims review has initiated uncertainty...
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CDI Strategies, Issue 19, September 16, 2010
Retaining written, templated, and verbal queries in document form is necessary to ensure CDI...
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CDI Strategies, Issue 19, September 16, 2010
Q: Our CDI specialists call the physicians when queries have not been answered. Sometimes the...
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CDI Strategies, Issue 19, September 16, 2010
by Steven Robinson, RN
Most physicians want to provide an accurate written picture of their...
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CDI Strategies, Issue 18, September 2, 2010
Nearly 300 people have already responded to the ICD-10 for Clinical Documentation Improvement...
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CDI Strategies, Issue 18, September 2, 2010
As facilities vie for government incentives to implement electronic health record systems they may...
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CDI Strategies, Issue 18, September 2, 2010
Confusing coding guidelines and insufficient documentation have made neoplasms a target area as...
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CDI Strategies, Issue 18, September 2, 2010
CMS requires that orders for healthcare services be authenticated using either a handwritten or...
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CDI Strategies, Issue 18, September 2, 2010
Q: If a CDI specialist or coder queries a physician and the response is written on the query letter...
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CDI Strategies, Issue 18, September 2, 2010
by Steven Robinson, RN
Most physicians want to provide an accurate written picture of their...
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Briefings on Coding Compliance Strategies, Issue 9, September 1, 2010
Learn about the FY 2011 IPPS final rule, the three-day payment rule, documentaiton and coding...
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CDI Strategies, Issue 17, August 19, 2010
We are currently seeking speakers to present at the 2011 ACDIS Fourth Annual Conference, to be held...
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CDI Strategies, Issue 17, August 19, 2010
The Centers for Medicare & Medicaid Services (CMS) recently approved the first “medical...
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CDI Strategies, Issue 17, August 19, 2010
When the University of Medicine and Dentistry of New Jersey (UMDNJ) hired Melanie Halpern, RN-BC...
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CDI Strategies, Issue 17, August 19, 2010
It may be too early to start intensive ICD-10-CM training for your coding and CDI team, but now is...
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CDI Strategies, Issue 17, August 19, 2010
Q: Should coders wait for the discharge summary before coding?
A: The answer is complicated...
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HIM-HIPAA Insider, Issue 32, August 17, 2010
Calculating a hospital’s case-mix index (CMI) is one way to gauge a CDI program’s...
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CDI Strategies, Issue 16, August 5, 2010
Three types of mistakes—insufficient documentation, miscoded claims, and medically...
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CDI Strategies, Issue 16, August 5, 2010
In response to a 30-question survey, 482 CDI professionals provided data about the number of staff...
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CDI Strategies, Issue 16, August 5, 2010
It’s not enough to know whether heart failure is systolic or diastolic. Congestive heart...
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CDI Strategies, Issue 16, August 5, 2010
Q: What should physicians know now about the level of specificity they’ll be required to...
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CDI Strategies, Issue 16, August 5, 2010
by Steven Robinson, RN
Most physicians want to provide an accurate written picture of their...
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CDI Strategies, Issue 16, August 5, 2010
On July 30, CMS issued the inpatient prospective payment system (IPPS) final rule to update...
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Briefings on Coding Compliance Strategies, Issue 8, August 1, 2010
You’ve started a clinical documentation improvement (CDI) program and collected data...
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Briefings on Coding Compliance Strategies, Issue 8, August 1, 2010
Learn about avoidable V code traps, why you shouldn't bypass coding rules for more money, why...
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CDI Strategies, Issue 15, July 22, 2010
There may be hope for hospitals carefully watching the proposed IPPS rule, praying for some...
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CDI Strategies, Issue 15, July 22, 2010
A special edition MLN Matters article released last week points to two common reasons for RAC...
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CDI Strategies, Issue 15, July 22, 2010
Assessment of clinical measures associated with end-of-life treatment could actually improve care...
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CDI Strategies, Issue 14, July 8, 2010
All told there were more than 500 CDI professionals in attendance at the 2010 ACDIS National...
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CDI Strategies, Issue 14, July 8, 2010
CMS released MLN Matters Special Edition Article #SE1019 to provide updated information about the...
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CDI Strategies, Issue 14, July 8, 2010
Congestive heart failure (CHF) is one example of a condition for which coders and CDI specialists...
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CDI Strategies, Issue 14, July 8, 2010
by Steven Robinson, RN
Most physicians want to provide an accurate written picture of...
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HIM-HIPAA Insider, Issue 26, July 6, 2010
Congestive heart failure (CHF) is one example of a condition for which coders and clinical...
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Briefings on Coding Compliance Strategies, Issue 7, July 1, 2010
Learn whether coders should delay sending a claim because of a missing discharge summary.
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CDI Strategies, Issue 13, June 24, 2010
The new, revised, and deleted ICD-9-CM codes, effective October 1, 2010, are now out. You can find...
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CDI Strategies, Issue 13, June 24, 2010
Q:I have a question about the discharge summary. When a physician documents a firm diagnosis (not...
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CDI Strategies, Issue 13, June 24, 2010
Despite some misconceptions to the contrary, a coder may report angina, unstable (411.1) if a...
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CDI Strategies, Issue 13, June 24, 2010
Q: Do you know of any recommended benchmarks or targets we should be hitting? For example...
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CDI Strategies, Issue 13, June 24, 2010
Current estimates indicate that more than 60% of all acute care hospitals have a CDI program in...
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CDI Strategies, Issue 12, June 10, 2010
Dear ACDIS members,
I want to remind you that comments to CMS on the FY 2011 IPPS proposed rule...
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CDI Strategies, Issue 12, June 10, 2010
by Steven Robinson, RN
Current estimates indicate that more than 60% of all acute care hospitals...
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CDI Strategies, Issue 12, June 10, 2010
The Program for Evaluating Payment Patterns Electronic Report (PEPPER) includes a wealth of...
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CDI Strategies, Issue 12, June 10, 2010
Nine hospitals in seven states will pay the United States more than $9.4 million combined to...
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CDI Strategies, Issue 12, June 10, 2010
by Melissa Varnavas, CPC, ACDIS associate director
In the fall of 2009 Leah Taylor, RN, CCDS, and...
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CDI Strategies, Issue 12, June 10, 2010
Many CDI professionals diligently perform the day-to-day tasks of documentation improvement. And...
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CDI Strategies, Issue 11, May 27, 2010
Next week more than 500 CDI specialists from around the country will meet at the Hyatt Regency in...
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CDI Strategies, Issue 11, May 27, 2010
The ACDIS CDI Work Group is pleased to present the results of its first CDI staffing survey. The...
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CDI Strategies, Issue 11, May 27, 2010
In April, CMS held an ICD-10 conference for software vendors, billing services, and clearinghouses...
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CDI Strategies, Issue 11, May 27, 2010
Q: Payers have been pushing back when a diagnosis appears in the discharge summary and not in the...
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CDI Strategies, Issue 11, May 27, 2010
by Steven Robinson, RN
Current estimates indicate that more than 60% of all acute care hospitals...
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CDI Strategies, Issue 10, May 13, 2010
Shortly after releasing its Clinical Documentation Improvement Toolkit in April, the American...
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CDI Strategies, Issue 10, May 13, 2010
CMS has been holding a number of open forum calls regarding its Recovery Audit Contractor (RAC...
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CDI Strategies, Issue 10, May 13, 2010
Effective January 1, 2011, CMS will start to accept up to 25 codes for secondary diagnoses. The...
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CDI Strategies, Issue 10, May 13, 2010
CDI specialists are getting too tied up with the minutiae of ICD-9-CM coding and DRG optimization...
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HIM-HIPAA Insider, Issue 18, May 11, 2010
On April 29, AHIMA issued a practice brief, “Guidance for Clinical Documentation Improvement...
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HIM-HIPAA Insider, Issue 17, May 4, 2010
Q. What should HIM staff members communicate to physicians now about the level of specificity...
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CDI Strategies, Issue 9, April 29, 2010
CMS released its fiscal year (FY) 2011 Inpatient Prospective Payment System (IPPS) proposed rule on...
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CDI Strategies, Issue 9, April 29, 2010
The American Health Information Management Association (AHIMA) published its Clinical Documentation...
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CDI Strategies, Issue 9, April 29, 2010
Despite the inclination of many hospital administrators to mechanize documentation and abstraction...
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CDI Strategies, Issue 9, April 29, 2010
Q: Our CDI specialists tend to ask questions that provide the physician with multiple options to...
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HIM-HIPAA Insider, Issue 15, April 20, 2010
Divisions between HIM and clinical documentation improvement (CDI) staff members are common. But in...
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CDI Strategies, Issue 8, April 15, 2010
News: Studies, anecdotal evidence cite burden of documentation as detriment to patient care
Recent...
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CDI Strategies, Issue 8, April 15, 2010
The Government Accountability Office (GAO) offered mixed reviews of CMS’ handling of the...
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CDI Strategies, Issue 8, April 15, 2010
Effective January 1, 2011, CMS is expanding the number of ICD-9 diagnosis and procedure codes...
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CDI Strategies, Issue 8, April 15, 2010
So you’ve made it through the rigors of the initial CDI implementation stage. Now it’s...
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CDI Strategies, Issue 8, April 15, 2010
by Steven Robinson, RN
Current estimates indicate that more than 60% of all acute care hospitals...
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Medical Records Briefing, Issue 4, April 1, 2010
Divisions between HIM and clinical documentation improvement (CDI) staff members are common. But in...
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Medical Records Briefing, Issue 4, April 1, 2010
This month's issue includes an article on HIMs role in surviving recovery audit contractor (RAC...
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CDI Strategies, Issue 7, April 1, 2010
A CDI Work Group run by the American Health Information Management Association (AHIMA) has been...
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CDI Strategies, Issue 7, April 1, 2010
by Robert S. Gold, MD
Too many organizations measure the effectiveness of their CDI program solely...
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CDI Strategies, Issue 7, April 1, 2010
Q: As manager of data integrity I oversee my facility’s CDI program. Can you recommend...
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CDI Strategies, Issue 6, March 18, 2010
The good news is that ACDIS has secured additional rooms at the Chicago Hyatt Regency for just $185...
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CDI Strategies, Issue 6, March 18, 2010
In 2008, the Office of Inspector General (OIG) reviewed a sample of nearly 300 Medicare...
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CDI Strategies, Issue 6, March 18, 2010
CMS will provide a a basic introduction to ICD-10-CM during its National Provider Conference Call...
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CDI Strategies, Issue 6, March 18, 2010
Although AHIMA’s October 2008 practice brief “Managing an Effective Query...
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CDI Strategies, Issue 6, March 18, 2010
For CDI specialists, the physician signature is one more critical piece of documentation to keep an...
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CDI Strategies, Issue 6, March 18, 2010
Like many CDI specialists, Janice Davis, RN, clinical documentation analyst at High Point (NC...
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HIM-HIPAA Insider, Issue 10, March 16, 2010
Divisions between HIM and clinical documentation improvement (CDI) staff members are common. But in...
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HIM-HIPAA Insider, Issue 10, March 16, 2010
In the April issue of MRB, you’ll find the following articles, and more!
EHR beat...
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CDI Strategies, Issue 5, March 4, 2010
The concept of standard operating procedures (SOP) might easily call to mind assembly lines or...
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CDI Strategies, Issue 5, March 4, 2010
Q: Do you code the procedure for tissue plasminogen activator (tPA) administration when it is done...
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CDI Strategies, Issue 5, March 4, 2010
Those who lived through the RAC demonstration project learned valuable lessons along the way...
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CDI Strategies, Issue 4, February 18, 2010
The next quarterly conference call is scheduled for Thursday, February 18, 2-3 p.m. E.S.T. ACDIS...
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CDI Strategies, Issue 4, February 18, 2010
Known primarily as a medical transcription and documentation firm, Tennessee-based Spheris was...
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CDI Strategies, Issue 4, February 18, 2010
Within the Alphabetic Index of ICD-9-CM is a Neoplasm table that assists coders in assigning...
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CDI Strategies, Issue 4, February 18, 2010
by Robert S. Gold, MD
Every so often, I come across some coding issues that recall other...
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CDI Strategies, Issue 4, February 18, 2010
ACDIS members who frequently use the CDI Talk message board already appreciate the hard work and...
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HIM-HIPAA Insider, Issue 5, February 9, 2010
As RACs begin to roll out complex reviews and request medical record documentation, compliant...
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CDI Strategies, Issue 3, February 4, 2010
In January, the Texas Health and Human Services Commission released its fiscal year 2009 annual...
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CDI Strategies, Issue 3, February 4, 2010
The nomination period for the 2010 CDI Professional of the Year award is open through March 15...
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CDI Strategies, Issue 3, February 4, 2010
The problem
According to a recent poll on the ACDIS Web site, 85% of members cope with physicians...
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CDI Strategies, Issue 3, February 4, 2010
The next quarterly conference call is scheduled for Thursday, February 18, 2-3 p.m. E.S.T. ACDIS...
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CDI Strategies, Issue 3, February 4, 2010
With approximately 30 applications up for consideration, ACDIS had a difficult time voting in four...
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CDI Strategies, Issue 2, January 21, 2010
In its January release, The Medicare Payment Advisory Commission (MedPAC) recommended Congress...
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CDI Strategies, Issue 2, January 21, 2010
Come October 2013, healthcare facilities will switch from reporting ICD-9-CM codes to the...
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CDI Strategies, Issue 2, January 21, 2010
Connolly Healthcare, CMS’ recovery audit contractor (RAC) for Region C, announced its first...
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CDI Strategies, Issue 2, January 21, 2010
Most organizations evaluate performance by looking at calendar year data, so set aside some time in...
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CDI Strategies, Issue 1, January 7, 2010
Dear ACDIS members,
Let me begin by saying that I want to thank you all for your...
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CDI Strategies, Issue 1, January 7, 2010
Some hospitals will start to receive Program for Evaluating Payment Patterns Electronic Reports...
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CDI Strategies, Issue 1, January 7, 2010
Effective January 1, CMS stopped paying for the CPT codes physicians use to bill consultations...
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CDI Strategies, Issue 1, January 7, 2010
Susan Borrego, MSN, RN, CCDS, and Michelle Limo, MSMIT, RN, CCDS represent the two-person team that...
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CDI Strategies, Issue 26, December 24, 2009
$3.75 million. That’s the amount California HMO Kaiser Permanente plans to pay the government...
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CDI Strategies, Issue 26, December 24, 2009
There are many schools of thought regarding which department should be in charge of a CDI...
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CDI Strategies, Issue 26, December 24, 2009
CDI administrators are constantly seeking simple solutions to educate fellow healthcare providers...
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CDI Strategies, Issue 26, December 24, 2009
Q: What are the differences between the MS-DRG and the APR-DRG systems?
A:Garri L...
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CDI Strategies, Issue 25, December 10, 2009
Facilities in 10 states could soon see medical record documentation requests for complex audits...
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CDI Strategies, Issue 25, December 10, 2009
A recently-released Comprehensive Error Rate Testing (CERT) report detailing coding/billing errors...
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CDI Strategies, Issue 25, December 10, 2009
Since physicians don’t always document pressure ulcers, carefully conduct investigations of...
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CDI Strategies, Issue 25, December 10, 2009
In an informal ACDIS poll earlier this year CDI specialists answered the question: How well do your...
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Briefings on Coding Compliance Strategies, Issue 12, December 1, 2009
Inside:
New E codes require detailed documentation
OIG focuses on hot-button issues in 2010 Work...
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CDI Strategies, Issue 24, November 26, 2009
The Senate Healthcare Reform Bill includes a proposal for expanding the RAC program. Specifically...
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CDI Strategies, Issue 24, November 26, 2009
At St. Mary’s Hospital in Passaic, NJ, Melanie Halpern, RN-BC, MBA, CCDS, clinical...
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CDI Strategies, Issue 24, November 26, 2009
Q: How I should query a physician when he documents: “Acute on chronic renal insufficiency...
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CDI Strategies, Issue 24, November 26, 2009
The American Hospital Association’s Coding Clinic for ICD-9-CM contains official advice from...
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CDI Strategies, Issue 23, November 12, 2009
Health Integrity LLC, the zone four (Colorado, New Mexico, Oklahoma, and Texas) Zone Program...
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CDI Strategies, Issue 23, November 12, 2009
Implementation of ICD-10-CM/PCS remains three years away. But it is not too soon to find out more...
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CDI Strategies, Issue 23, November 12, 2009
With so much attention on healthcare reform and CMS’ shift toward paying for quality, CDI...
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CDI Strategies, Issue 23, November 12, 2009
CDI professionals across the country understand the benefit of informal, informational networking...
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CDI Strategies, Issue 23, November 12, 2009
Q: We recently heard from our process management company that after several clients have had the...
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CDI Strategies, Issue 23, November 12, 2009
Editor’s note:The following items have been updated on the ACDIS Web site...
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CDI Strategies, Issue 23, November 12, 2009
Editor’s note: The ACDIS Blog contains important association information as well as tips and...
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Briefings on Coding Compliance Strategies, Issue 11, November 1, 2009
Inside:
Prepare for ICD-10 with anatomy/physiology education
Determine your coders’ need...
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CDI Strategies, Issue 22, October 29, 2009
CDI specialists often underestimate the importance of the dictated history and physical (H&P...
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CDI Strategies, Issue 22, October 29, 2009
Sometimes documentation mistakes caught by CDI professionals are the simple ones. Like an incorrect...
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CDI Strategies, Issue 22, October 29, 2009
Q: How has switching to a severity of illness (SOI)/ risk of mortality (ROM) system affected your...
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CDI Strategies, Issue 22, October 29, 2009
Sepsis. Severe sepsis. SIRS. Septicemia. Unfortunately, this isn’t a case of “tomato...
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CDI Strategies, Issue 22, October 29, 2009
Editor’s note:The following items have been updated on the ACDIS Web site...
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CDI Strategies, Issue 22, October 29, 2009
Editor’s note: The ACDIS Blog contains important association information as well as tips and...
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CDI Strategies, Issue 21, October 15, 2009
With all the attention these days squarely on Recovery Audit Contractors (RAC), CDI specialists...
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CDI Strategies, Issue 21, October 15, 2009
Many hospitals feared a 1.9% reduction in payment for 2010, but they’ll actually see a 2.1...
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CDI Strategies, Issue 21, October 15, 2009
An HCPro Inc. poll survey posted this week asked healthcare compliance professionals if their CDI...
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Briefings on Coding Compliance Strategies, Issue 10, October 1, 2009
Inside:
Use productivity benchmarks to set coding standards
Roller-coaster fall results in...
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CDI Strategies, Issue 20, October 1, 2009
Many CDI programs use Excel-spreadsheets to track and organize their query processes. More and...
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CDI Strategies, Issue 20, October 1, 2009
CDI specialists appreciate this issue well. Understanding some of the reasons for inappropriate...
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CDI Strategies, Issue 20, October 1, 2009
The most recent Coding Clinic, third quarter 2009, contains an entry on glioblastoma with vasogenic...
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HIM-HIPAA Insider, Issue 39, September 29, 2009
Question: A patient came into the ER with complaints of a headache and facial pain. The ER...
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HIM-HIPAA Insider, Issue 39, September 29, 2009
The present-on-admission (POA) indicator refers to conditions that are present at the time an order...
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CDI Strategies, Issue 19, September 17, 2009
While it may be familiar information for those working in the hospital payment world for years, CDI...
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CDI Strategies, Issue 19, September 17, 2009
For a program that spends $400 billion annually saving one or two million dollars seems like a...
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CDI Strategies, Issue 19, September 17, 2009
As a reminder, several new codes have been designated as complications/comorbidities (CCs) and...
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CDI Strategies, Issue 19, September 17, 2009
The sequencing of respiratory failure depends on the reason for admission. When respiratory failure...
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CDI Strategies, Issue 19, September 17, 2009
Editor’s note: The following items have been updated on the ACDIS Web site...
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CDI Strategies, Issue 19, September 17, 2009
Editor’s note: The ACDIS Blog contains important association information as well as tips and...
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CDI Strategies, Issue 18, September 3, 2009
Following a targeted review of 250 claims with DRG 247, TrailBlazer, the Medicare Administrative...
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CDI Strategies, Issue 18, September 3, 2009
Editor’s Note: The following tip was excerpted from the article “Tips for problematic...
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CDI Strategies, Issue 18, September 3, 2009
Editor’s note: The following Q&A first appeared in the August 20, 2009, edition of CDI...
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CDI Strategies, Issue 18, September 3, 2009
Editor’s note: The following items have been updated on the ACDIS Web site...
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HIM-HIPAA Insider, Issue 32, August 11, 2009
By now, most coders are aware that ICD-10 will usher in expanded codes that will require additional...
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CDI Strategies, Issue 16, August 6, 2009
Concern regarding CMS’ 2010 Inpatient Prospective Payment System (IPPS) proposed rule...
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CDI Strategies, Issue 16, August 6, 2009
When creating a CDI program, you first have to determine its organizational structure. Will it live...
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CDI Strategies, Issue 16, August 6, 2009
It's important to develop a structured process of performing quality audits of your CDI staff, says...
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Briefings on Coding Compliance Strategies, Issue 8, August 1, 2009
More hospitals will likely develop clinical documentation improvement (CDI) programs as ICD-10...
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Briefings on Coding Compliance Strategies, Issue 8, August 1, 2009
Inside:
What would you do? Know your ethical obligations
Improve documentation with strong CDI...
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CDI Strategies, Issue 15, July 23, 2009
One in five Medicare beneficiaries who leave the hospital today will re-enter the hospital within a...
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CDI Strategies, Issue 15, July 23, 2009
(Editor’s note: CDI specialists may wish to provide the following tip to their physicians in...
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CDI Strategies, Issue 15, July 23, 2009
Q: When coded, will the five ICD-9 diagnosis codes which turn off if the patient expires for use in...
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CDI Strategies, Issue 15, July 23, 2009
Editor’s note: The following items have been updated on the ACDIS Web site...
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CDI Strategies, Issue 15, July 23, 2009
Editor’s note: The ACDIS Blog contains important association information as well as tips and...
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CDI Strategies, Issue 14, July 9, 2009
In April the American Health Information Management Association (AHIMA) asked for volunteers to...
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CDI Strategies, Issue 14, July 9, 2009
Our facility is wondering how long to keep queries. In a previous institution in which I...
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CDI Strategies, Issue 14, July 9, 2009
Editor’s note: The ACDIS Blog contains important association information as well as tips and...
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Medical Records Briefing, Issue 7, July 1, 2009
This month’s expanded issue includes our 4-page quarterly insert about electronic health...
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CDI Strategies, Issue 13, June 25, 2009
Those who took the Certified Clinical Documentation Specialist (CCDS) examination in Las Vegas can...
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CDI Strategies, Issue 13, June 25, 2009
Do established CDI programs typically track mortality rates concurrently or by trending historical...
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CDI Strategies, Issue 13, June 25, 2009
Along with their daily duties of chart review, CDI specialists should consider themselves as...
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CDI Strategies, Issue 13, June 25, 2009
On the ACDIS Web site
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CDI Strategies, Issue 13, June 25, 2009
On the ACDIS Blog
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HIM-HIPAA Insider, Issue 25, June 23, 2009
On June 15, the American Hospital Association (AHA) provided comments to CMS about changes outlined...
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CDI Strategies, Issue 12, June 11, 2009
Editor’s note: The ACDIS Blog contains important association information as well as tips and...
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CDI Strategies, Issue 12, June 11, 2009
Editor’s note: The following items have been updated on the ACDIS Web site...
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CDI Strategies, Issue 12, June 11, 2009
Will a Hospital Acquired Condition (HAC), when coded, still affect severity of illness (SOI)/risk...
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CDI Strategies, Issue 12, June 11, 2009
Government payers previously believed that physician queries opened opportunities for the...
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CDI Strategies, Issue 12, June 11, 2009
When dealing with difficult documentation issues such congestive heart failure (CHF) consider...
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CDI Strategies, Issue 12, June 10, 2009
Need to get your physicians onboard with your clinical documentation improvement program? Show them...
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CDI Strategies, Issue 11, May 28, 2009
Sample query note: How to construct appropriate queries for bowel disease
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CDI Strategies, Issue 11, May 28, 2009
CDI specialists who seek to alter code sequences in order to optimize CC/MCC capture and case mix...
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CDI Strategies, Issue 11, May 28, 2009
Q: Last year a cardiologist provided an educational session for our coding auditor and the...
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CDI Strategies, Issue 10, May 14, 2009
Editor’s note: The ACDIS Blog contains important association information as well as tips...
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CDI Strategies, Issue 10, May 14, 2009
Editor’s note: The following items have been updated on the ACDIS Web site...
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CDI Strategies, Issue 10, May 14, 2009
Verbal queries remain a source of contention for hospitals simply because these queries are...
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CDI Strategies, Issue 10, May 14, 2009
Many reported post-operative complications may not really be complications of care at all, says...
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HIM-HIPAA Insider, Issue 18, May 4, 2009
The long-awaited fiscal year (FY) 2010 Inpatient Prospective Payment System (IPPS) proposed rule is...
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CDI Strategies, Issue 9, April 30, 2009
Editor’s note: The ACDIS Blog contains important association information as well as tips and...
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CDI Strategies, Issue 9, April 30, 2009
Editor’s note: The following items have been updated on the ACDIS Web site...
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CDI Strategies, Issue 9, April 30, 2009
CDI specialists should seek to promote the three “Rs” to improve their...
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APCs Insider, Issue 16, April 17, 2009
Everyone knows that an immense amount of teamwork is necessary for a CDI program to truly be...
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CDI Strategies, Issue 8, April 16, 2009
On the ACDIS Blog
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CDI Strategies, Issue 8, April 16, 2009
On the ACDIS Web site
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CDI Strategies, Issue 8, April 16, 2009
My facility’s policy requires us to address all queries to the attending physician...
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CDI Strategies, Issue 8, April 16, 2009
Successful CDI programs begin with the selection of competent and cohesive teams. As CDI programs...
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CDI Strategies, Issue 7, April 2, 2009
Editor’s Note: The ACDIS Blog allows us to post important association information as well as...
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CDI Strategies, Issue 7, April 2, 2009
Many physicians fail to document conditions associated with acute kidney injury (AKI) and chronic...
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CDI Strategies, Issue 7, April 2, 2009
Many CDI programs use nurses as their primary concurrent reviewers, the argument being that a...
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CDI Strategies, Issue 7, April 1, 2009
Other than explaining to the physician that we code chronic respiratory failure separately from the...
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CDI Strategies, Issue 7, April 1, 2009
It used to take up to three months to review medical records of expired patients in order to track...
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CDI Strategies, Issue 5, March 5, 2009
Consider 10 reasons for adopting an electronic query process in your CDI program
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CDI Strategies, Issue 5, March 5, 2009
ACDIS Blog: Keep up-to-date on what's going on in the association
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CDI Strategies, Issue 5, March 5, 2009
Stress synergy and collaboration to make your CDI program work
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CDI Strategies, Issue 3, February 5, 2009
Editor’s note: ACDIS members have access to tools and forms and a number of educational...
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CDI Strategies, Issue 3, February 5, 2009
Note: ACDIS appreciates receiving questions from our readers. We cannot promise to answer every...
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CDI Strategies, Issue 3, February 5, 2009
This excerpt highlights information from the white paper, “Master physician queries...
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CDI Strategies, Issue 2, January 22, 2009
From veteran programs to new CDI initiatives, CDI department managers should seek their...
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CDI Strategies, Issue 1, January 8, 2009
What’s the basic role and purpose of a physician champion/advisor in a CDI program? Do you...
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CDI Strategies, Issue 1, January 8, 2009
Consider the following techniques to improve physician education and awareness of your CDI program.
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CDI Strategies, Issue 1, January 8, 2009
Question: Part of our clinical support for determining the presence of congestive heart failure...
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CDI Strategies, Issue 1, January 8, 2009
As a reminder, ACDIS has now added Susan Calabro as a full-time member relations specialist. If you...
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Medical Records Briefing, Issue 1, January 1, 2009
We all do a great job in documenting our patients’ history and physical exams. We all...
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Briefings on Coding Compliance Strategies, Issue 1, January 1, 2009
Editor’s note: Last month in BCCS, we offered an overview of AHIMA’s new query brief...
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Briefings on Coding Compliance Strategies, Issue 1, January 1, 2009
Get to know your bleeds to ensure proper coding by Robert S. Gold, MD Consider the following...
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CDI Strategies, Issue 25, December 11, 2008
Where can I find documentation that says that suspected or probable diagnoses have to be in the...
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CDI Strategies, Issue 25, December 11, 2008
Since CDI professionals are on the front lines of reviewing physician documentation, they should be...
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CDI Strategies, Issue 25, December 11, 2008
Note: Bonus issue of CDI Strategies this week
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CDI Strategies, Issue 24, December 4, 2008
When a clinical condition suggests a more specific diagnosis, and a physician from a different...
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CDI Strategies, Issue 24, December 4, 2008
CMS on November 25 posted an Issues Paper on its Web site relating to its plan to transition...
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Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008
Officials answer questions during special ODF By now, one point remains clear: CMS has halted the...
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Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008
Coders and CDI specialists now have concrete guidance regarding when, how, and to whom they should...
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Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008
Since October 1, 2007, providers have been adapting to a revised hospital inpatient reimbursement...
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Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008
CMS discusses RAC expansion, ICD-10, and never events CMS hosted a Hospital & Hospital Quality...
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Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008
by Robert S. Gold, MD Applying the present-on-admission (POA) indicator to pressure ulcers is no...
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HIM-HIPAA Insider, Issue 45, November 18, 2008
Q: What present on admission (POA) indicator should we assign when a patient presents to the...
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CDI Strategies, Issue 0, November 17, 2008
The Association of Clinical Documentation Improvement Specialists (ACDIS) is currently seeking four...
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CDI Strategies, Issue 23, November 13, 2008
What present on admission (POA) indicator should we assign when a patient presents to the hospital...
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CDI Strategies, Issue 23, November 13, 2008
On October 20, the AMIA and AHIMA released Proposed Health Information Management and Informatics...
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CDI Strategies, Issue 23, November 13, 2008
CMS has delayed the Medicare Recovery Audit Contractor (RAC) permanent program and put a moratorium...
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CDI Strategies, Issue 23, November 13, 2008
A recently released white paper by the Institute for Healthcare Improvement contains some sound...
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CDI Strategies, Issue 23, November 13, 2008
ACDIS seeking new advisory board members
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Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008
Gastrointestinal (GI) bleed and its manifestations can be confusing without some insight into...
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Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008
The ICD-9-CM Manual provides many helpful tools you can use to your advantage. For example, despite...
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Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008
Most surgeons find carcinoid tumors incidentally, either during the postmortem exam when a patient...
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Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008
Just because a physician documents a condition during the postoperative period doesn’t mean...
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Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008
Forty percent of Medicare admission denials relate to improper one-day stays. If this statistic...
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CDI Strategies, Issue 22, October 30, 2008
The third quarter, 2008 AHA Coding Clinic for ICD-9-CM contains valuable new guidance for CDI...
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CDI Strategies, Issue 22, October 30, 2008
Are there any standards about how many records to review per day? How about staffing size?
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CDI Strategies, Issue 22, October 29, 2008
Since October 1, 2007, Medicare providers have been adapting to a revised hospital inpatient...
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CDI Strategies, Issue 21, October 16, 2008
CMS announced the new Medicare Recovery Audit Contractors (RACs) for its permanent nationwide...
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CDI Strategies, Issue 21, October 16, 2008
The CDI team at South Shore Hospital (SSH) in Weymouth, MA, has been tracking results of its...
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CDI Strategies, Issue 21, October 16, 2008
Too many CDI specialists focus strictly on DRG assignment when reviewing medical records when they...
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CDI Strategies, Issue 20, October 2, 2008
ACDIS members are looking for professional recognition, further definition of their competencies...
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CDI Strategies, Issue 20, October 2, 2008
CMS recently updated all sections of the Hospital-Acquired Conditions (HAC) and Present on...
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CDI Strategies, Issue 20, October 2, 2008
The American Health Information Management Association (AHIMA) on Sept. 29 released its...
