Health Information Management Articles by Topic: Clinical Documentation Improvement
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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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JustCoding News: Inpatient, Issue 46, November 11, 2009
Many clinical documentation improvement specialists and coders struggle with the CC and MCC lists...
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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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JustCoding News: Inpatient, Issue 44, October 28, 2009
There is a new focus on capturing severity of illness (SOI) and risk of mortality (ROM), and...
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JustCoding News: Inpatient, Issue 44, October 28, 2009
Physicians may document appropriate terminology to describe a patient’s condition(s), however...
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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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JustCoding News: Inpatient, Issue 42, October 14, 2009
Physicians may document clinical indicators of significant conditions, but they may not actually...
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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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JustCoding News: Inpatient, Issue 40, September 30, 2009
Reporting complications of surgery is often likened to a tug of war between hospitals and...
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HIM Connection, 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 Connection, 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 Connection, 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 Connection, 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 Connection, 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 Weekly Monitor, 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 Connection, 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...