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Displaying records 1 to 20 out of 4844 results for "Clinical documentation specialist".
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SORT RESULTS BY: RELEVANCY | PUBLICATION DATE
Now in its second edition, clinical-documentation-improv
APRIL 9, 2014
JUSTCODING
Now in its second edition, clinical-documentation-improv
JUNE 4, 2014
JUSTCODING
Now in its second edition, clinical-documentation-improv
AUGUST 13, 2014
JUSTCODING
HCPro, Inc. and the Association of Clinical Documentation Improvem
ACDIS, the Association of Clinical Documentation Impro
APRIL 7, 2011
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
JANUARY 19, 2016
The Association of Clinical Documentation Improvement Specialists (ACDIS) last week updated its
OCTOBER 13, 2015
The first Clinical Documentation Improvement Week is taking place from September
SEPTEMBER 21, 2011
Friday, April 11 is the deadline to apply for the Certified Clinical Documentation Specia
ACDIS is proud to celebrate the 3,000th Certified Clinical Documentation Specialist (CCDS) creden
HCPro Inc., a leader in healthcare education and training, and the Association of Clinical Docume
AUGUST 24, 2010
The Association of Clinical Documentation Improvement Specialists (ACDIS), the premier healthcar
SEPTEMBER 10, 2012
ACDIS, the Association of Clinical Documentation Improvement Specialists, the leading national as
FEBRUARY 8, 2011
Q: Can you clarify the expectations related to documenting the discussion betwee
Las Vegas, NV--Almost 400 clinical documenation specialists gathered in Las Vega
JUNE 2, 2008
The Certified Clinical Documentation Specialist (CCDS) exam hit a pretty big milestone last weeke
HCPro, Inc., and ACDIS, the Association of Clinical Documentation Improvement Specialists, today
JUNE 15, 2011
The focus for clinical documentation improvement (CDI) specialists has historically been on the i
FEBRUARY 21, 2017
Proper documentation is critical when it comes to supporting medical necessity and providing qual
An outpatient clinical documentation improvement (CDI) program should be aligned with a fa
By Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI CDI specialist
CDI specialists are in high demand, and finding experienced staff can be difficult. That often me
Coders and clinicians seem to speak different languages. CDI specialists often serve as the trans
AUGUST 26, 2015
JUSTCODING
In an ideal world, all coders and CDI specialists would get along well and work together with min
The new AHA Coding Clinic for ICD-10-CM and ICD-10-PCS cleared up some confusion regarding
  by Sharme Brodie, RN, CCDS Many coders and CDI specialists have memorized
FEBRUARY 11, 2015
JUSTCODING
Q: Can you code strictly from emergency department (ED) documentation? Can you code from tes
DECEMBER 16, 2015
JUSTCODING
Q: I’m in a little debate: Does documentation of the patient’s body mass in
MAY 7, 2014
JUSTCODING
The Association of Clinical Documentation Improvement Sp
OCTOBER 1, 2010
The American Health Information Management Association (AHIMA) and the Association of Clinical Do
MARCH 11, 2015
JUSTCODING
ACDIS, the Association of Clinical Documentation Improvement Specialists
AUGUST 1, 2012
Q: In the past few weeks, we noticed physicians are documenting acute conge
Coders and clinical documentation improvement specialists need a clear understanding of how to us
NOVEMBER 20, 2013
JUSTCODING
The Association of Clinical Documentation Improvement Specialists (ACDIS) released a new position
NOVEMBER 5, 2014
by Kirsten Dize Strong documentation is key in home health, and implementation o
Two experts explain what new accreditation specialists need to know Editor&
SEPTEMBER 1, 2017
Whether your new CDI specialist is a nurse who needs to learn coding and reimbursement basics, o
While many case managers today work closely with clinical documentation improvement (CDI) special
JANUARY 5, 2016
To accurately interpret and code physician documentation, the HIM department should employ
JUNE 4, 2014
JUSTCODING
Although documentation matters more and more in today’s world of ever-changing regulations,
AUGUST 4, 2017
Those interested in taking the Certified Clinical Documentation Specialists (CCDS) credential exa
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
DECEMBER 30, 2015
Most coders and clinical documentation improvement (CDI) specialists are familiar with the Unifor
JANUARY 14, 2015
JUSTCODING
At ACDIS, it’s no surprise when we hear about clinical documentation improvement efforts
In 2016, those sitting for the Certified Clinical Documentation Specialist (CCDS) exam face the b
Q: Over the years I have heard differing opinions regarding whether clinical or coding exp
JANUARY 28, 2015
JUSTCODING
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
FEBRUARY 9, 2015
The Association of Clinical Documentation Improvement Specialists (ACDIS) honored the nation&rsqu
MAY 25, 2016
A patient presents to the ED with a headache, nausea, and vomiting. The physician documented that
FEBRUARY 25, 2015
JUSTCODING
MAY 6, 2015
JUSTCODING
The Association of Clinical Documentation Improvement Specialists (ACDIS) just launched a redesig
JUNE 20, 2016
  Coders and clinical documentation improvement (CDI) specialists may not always a
JUNE 17, 2015
JUSTCODING
Q: Our physicians document a diagnoses of pneumonia but do not normally make a specific
APRIL 9, 2014
JUSTCODING
Q: The primary physician documented subacute cerebral infarction and I am wondering whe
NOVEMBER 5, 2014
JUSTCODING
ACDIS—the Association of Clinical Documentation Improvement Specialists—announced tod
MARCH 18, 2014
The following changes to the Certified Clinical Documentation Specialist (CCDS) credential
APRIL 9, 2014
JUSTCODING
Q: The physician documented “encephalopathy” in the record of a patient who wa
Q: I am looking for documentation or physician education tips related to ventilator manage
By James S. Kennedy, MD, CCS, CDIP The physician documented “encephalopathy&
MARCH 25, 2015
JUSTCODING
  Q: Is it okay to code a diagnosis if the physician documents two diagnoses usin
SEPTEMBER 24, 2014
JUSTCODING
Coders are tasked with telling a patient’s story based on the documentation in the m
MAY 20, 2015
JUSTCODING
The Association of Clinical Documentation Improvement Specialists (
FEBRUARY 23, 2012
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s pre
FEBRUARY 16, 2015
In 2016, those sitting for the Certified Clinical Documentation Specialist (CCDS) exam face the b
The Association of Clinical Documentation Improvement Specialists (ACDIS) will soon be launching
Effective July 1, 2016, ACDIS will institute a policy and penalty fee for late Certified Clinic
The Association of Clinical Documentation Improvement Specialists (ACDIS) will soon be launching
Referring patients to specialists is fairly routine for most primary care practices, but it can b
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician document
SEPTEMBER 3, 2014
JUSTCODING
SEPTEMBER 23, 2015
JUSTCODING
Brian Murphy, Director of the Association of Clinical Docum
AUGUST 13, 2012
In recent years, hospitals have increasingly focused on creating clinical documentation improveme
JULY 29, 2015
JUSTCODING
NOVEMBER 19, 2014
JUSTCODING
The National Association of Clinical Nurse Specialists (NACNS) has gathered experts to focus on
FEBRUARY 25, 2015
JUSTCODING
Q:  Should a blood tranfusion received at an outpatient clinic be coded on the
SEPTEMBER 9, 2015
JUSTCODING
I’m always excited to read an article about clinical documentation improvement in the mains
Due to high demand, ACDIS added an additional CDI Boot Camp to its 2014 roster. CDI specialists can
Q: Our CDI specialists will present to our inpatient rehabilitation department (including
JustCoding’s Clinical Conditions Encyclopedia is the perfect reso
OCTOBER 1, 2014
JUSTCODING
Incomplete documentation in patient clinical records can cause your organization legal and settle
SEPTEMBER 18, 2019
By Cheryl Ericson, MS, RN, CCDS, CDIP Many clinical documentation improvement (CDI
JULY 29, 2015
JUSTCODING
Providers don’t often receive education on clinical documentation, which can be a challenge
Increasing accountability in medicine has brought more attention to the importance of clinical do
SEPTEMBER 23, 2016
The electronic health record has been a game-changer for CDI specialists, automating review proce
The Association of Clinical Documentation Improvement Speci
The Advanced CDI Boot Camp is designed for established clinical documentation depar
Q: Should I query for chronic respiratory failure if the documentation indicates the patient
OCTOBER 8, 2014
JUSTCODING
Struggling to identify the clinical indicators needed to qualify a diagnosis as a complica
Struggling to identify the clinical indicators needed to qualify a diagnosis as a complica
Struggling to identify the clinical indicators needed to qualify a diagnosis as a complication/co
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
JANUARY 29, 2016
Blogs from industry experts in healthcare that keep users up-to-date on the latest happenings in their fields.
Struggling to identify the clinical indicators needed to qualify a diagnosis as a complication/co
APRIL 22, 2015
JUSTCODING
 Documentation
Using a streamlined approach to EHR documentation may help reduce stress for resident, according
AUGUST 7, 2015
The sitemap of HCPro gives you convenient, once click access to each of our departments, e-Newsletters, newsletters, and blogs.
SEPTEMBER 4, 2008
Struggling to identify the clinical indicators needed to qualify a diagnosis as a complication/c
Privileging Training varies widely, as does practice, for specialist
AA best practice should identify clinical actions—assessment, teaching, procedures, coordin
Best practice should identify clinical actions—assessment, teaching, procedures, coordinati
  When a provider fails to document whether a patient diagnosed with monoplegia ha
MAY 13, 2015
JUSTCODING
As retail clinics expand in number and in scope of services, they could emerge as a threat to som
Primary care physicians (PCP) are in a difficult spot these days. Paid less than specialists, man
  FEES Studies Q&A with Stefanie Corbett, postacute regulatory specialist at HCPro
NOVEMBER 22, 2017
  New Survey Process Q&A with Stefanie Corbett, DHA, postacute regulatory specialist at HCPro
DECEMBER 22, 2017
SEPTEMBER 24, 2014
JUSTCODING
 Although documentation matters more and more in today?s world of ever-changing regulations, med
AUGUST 4, 2017
  Why are physician queries so critical to accurate documentation and coding? The an
by Deepak Gupta, MD, anesthesiology clinical assistant professor; and Sarwan Kumar, MD, inter
APRIL 28, 2017
SEPTEMBER 23, 2015
JUSTCODING
Insufficient documentation is the leading cause of improper payments for claims involving referri
OCTOBER 28, 2015
JUSTCODING
We want physicians to be very clear in their documentation about what’s wrong with the pati
Advancements in electronic health records (EHR) have improved nursing documentation and patient s
JANUARY 26, 2017
  A Comprehensive Error Rate Testing (CERT) study found insufficient documentation
JULY 22, 2015
JUSTCODING
JUNE 18, 2014
JUSTCODING
To date, Clinical Learning Environment Review (CLER) visits are scheduled to occur every 18 to 2
OCTOBER 27, 2017
Medicare allows electronic signatures as “alternative signatures” on clinical records
DECEMBER 3, 2014
JUSTCODING
By utilizing the information documented in the record, coders can report the BMI from a dietitian
Q: I work in a large, provider-based orthopedic clinic with a rheumatology department tha
Clinical documentation is often overlooked during residency, yet without proper training, new ph
SEPTEMBER 9, 2016
Q: I am the only CDI specialist in our 150-bed facility. I have held the position for thr
by Brian Ward Many hospitals and clinics struggle with the same physical
JANUARY 28, 2021
by Brian Ward Many hospitals and clinics struggle with the same physical
JANUARY 10, 2021
Documentation example for coders in
OCTOBER 29, 2014
JUSTCODING
Documentation example in
MARCH 4, 2015
JUSTCODING
"[A]s we enter into clinical practice, physicians face the burdens of documentation and reg
SEPTEMBER 17, 2015
In the early days of clinical documentation improvement programs many staff members reported up t
Residency training typically serves as physicians’ first exposure to the clinical document
AUGUST 11, 2017
Q: I work in a large, provider-based orthopedic clinic with a rheumatology department that
Documentation Documentation
Coding and documentation should tell a patient's complete story. With the greater specific
Editor’s note: This is the second of a series of stories that will help medical clinics
Last Tuesday, NAHC submitted official comments to CMS on a pair of proposed clinical templates (o
Coders and CDI specialists don’t always identify the same areas of concern; sometime
SEPTEMBER 24, 2014
JUSTCODING
Coders and CDI specialists don’t always identify the same areas of concern; sometime
SEPTEMBER 17, 2014
JUSTCODING
If the hospital documentation, including history and physical and progress notes, doesn’t s
There has been a fair amount of coverage on the documentation requirements needed to assign ICD-1
No. The regulations do not mandate any particular form or format for documentation or confirmati
In the rush to complete ICD-10 coding education, documentation improvement, and system updates, H
OCTOBER 21, 2015
JUSTCODING
Local ACDIS chapters provide a vital networking and educational service to clinical documentation
FEBRUARY 11, 2015
JUSTCODING
by Deepak Gupta, MD, anesthesiology clinical assistant professor; and Sarwan Kumar, MD, inter
FEBRUARY 14, 2018
  CMS continues expand its ICD-10 Clinical Concepts Series for specialties on
AUGUST 26, 2015
JUSTCODING
Q: In terms of coding blood transfusions, does the documentation of which intravenous (IV)
Take a close look at the documentation guidelines that CMS suggests for the practice improvement
Q: Is the statement “please document in a progress note to capture the severity of i
DECEMBER 23, 2014
JUSTCODING
We all know that ICD-10 codes will require more complete documentation. We’ve been t
Insufficient documentation led to approximately 97% of improper payments for kyphoplasty a
JULY 23, 2014
JUSTCODING
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician document
MARCH 19, 2014
JUSTCODING
APRIL 30, 2014
JUSTCODING
MAY 7, 2014
JUSTCODING
AUGUST 6, 2014
JUSTCODING
Documentation sample for coders in
NOVEMBER 12, 2014
JUSTCODING
MAY 13, 2015
JUSTCODING
Q: Is it okay to code a diagnosis if the physician documents two diagnoses using
Written by Stefanie Corbett, DHA, post-acute regulatory specialist for HCPro &nbs
JANUARY 5, 2018
NOVEMBER 20, 2013
JUSTCODING
OCTOBER 8, 2014
JUSTCODING
Coders and CDI specialists don’t always identify the same areas of concern; sometime
SEPTEMBER 10, 2014
JUSTCODING
AUGUST 19, 2015
JUSTCODING
NOVEMBER 4, 2015
JUSTCODING
It’s an age-old question: How do you get physicians to support documentation improvement ef
by Kirsten Dize Make completing documentation in the home a requirement for all
Q: I am a coder in a hospital outpatient setting. Our physicians document drug use in s
JULY 22, 2015
JUSTCODING
Q: I work in a large, provider-based orthopedic clinic with a rheumatology department t
NOVEMBER 12, 2014
JUSTCODING
  Documentation standards
JANUARY 1, 2015
New on JustCoding Platinum! New ICD-10-CM documentation examples in
JULY 9, 2014
JUSTCODING
CMS recently updated its Clinical Laboratory Amendments (CLIA) for lab work at critical access ho
APRIL 12, 2016
SEPTEMBER 23, 2015
JUSTCODING
Q: The primary physician documented subacute cerebral infarction and I am wondering whethe
Focus on documentation. CMS believes it is the responsibility of the homecare provider to attempt
APRIL 23, 2014
JUSTCODING
Use this policy, shared courtesy of Lynda Bailey, RN, BSN, CSHA, accreditation specialist for
MAY 30, 2020
Use this policy, shared courtesy of Lynda Bailey, RN, BSN, CSHA, accreditation specialist fo
by Brian Ward Back in 2015, New Orleans’ first-ever clinic special
Referring patients to specialists is fairly routine for most primary care practices, but it can b
Q: If a is patient admitted with malnutrition and the physician documented the patien
The patient care plan (485) is not a stand-alone documentation system; it is the legal record of
APRIL 23, 2014
JUSTCODING
Regardless of the clinical background of those responsible for reviewing documentation, it can be
SEPTEMBER 3, 2014
JUSTCODING
Physician documentation for the use of osteogenic stimulators for nonunion of fractures is often
JANUARY 28, 2015
JUSTCODING
by Josh Poltilove Restructure clinical managers’ positions so they function
AUGUST 27, 2014
JUSTCODING
Ensure employee compliance with safety requirements in physician offices, clinics, and other faci
DECEMBER 23, 2014
  Creating a new position to assume a physician’s documentation duties may l
JULY 15, 2015
JUSTCODING
Announced in 2012, the ACGME’s Clinical Learning Environment Review (CLER) was established
JULY 21, 2017
A patient comes into the ED following an automobile accident. The physician documents that the pa
Does your hospital have a clinical documentation improvement (CDI) program (i.e., a department, s
APRIL 23, 2014
JUSTCODING
Does your hospital have a clinical documentation improvement (CDI) program (i.e., a department, s
APRIL 30, 2014
JUSTCODING
MAY 14, 2014
JUSTCODING
Incidents reports are a pain to fill out, but vital for documenting what happened and for pro
SEPTEMBER 3, 2015
The proof of medical necessity strictly relies on the MD documentation and diagnosis and the skil
APRIL 9, 2014
JUSTCODING
JUNE 4, 2014
JUSTCODING
In which format would you be most likely to access a clinical conditions library, which includes
JULY 9, 2014
JUSTCODING
In which format would you be most likely to access a clinical conditions library, which includes
JULY 16, 2014
JUSTCODING
OCTOBER 22, 2014
JUSTCODING
New EP: Avoid RFIs by keeping documents and service manuals in library “If it was
JANUARY 1, 2018
Documenting medical necessity has become a big topic over the last several years and there has be
MARCH 22, 2019
Q: Our facility is considering having our coders and CDI specialists “go–live&
New EP: Avoid RFIs by keeping documents and service manuals in library “If it was
DECEMBER 1, 2017
Documentation: Getting the details right Joint Commission eli
DECEMBER 6, 2016
By Christopher Cheney Vision-impaired hospital patients have worse clinical outcom
MAY 8, 2019
You’ve probably heard that you need to beef up your clinical knowledge for ICD-10-CM
Jeff comes in to the Fix ‘Em Up Clinic complaining of shortness of breath, a persistent cou
Agencies should consider implementing a Utilization Review (UR) model or a clinical manager as a
  Q&A: Documentation for body mass index
  Skilled Services: How to document for proper reimbursement
OCTOBER 9, 2015
  Featured member resource: ADR appeal documentation checklist
NOVEMBER 16, 2018
Managers should not assume that they can review every guideline, every item in Coding Clinic,
MAY 7, 2014
JUSTCODING
Q: If the clinical impression is physical assault, vomiting, blunt injury to abdomen, a
JUNE 11, 2014
JUSTCODING
Q: We are an independent outpatient end-stage renal disease clinic. When we administer a blo
NOVEMBER 11, 2015
JUSTCODING
NOVEMBER 19, 2014
JUSTCODING
Are you an accreditation specialist or handle survey preparation for your organization? If so, we
APRIL 21, 2015
Midwest Women’s Healthcare Specialists in Kansas City, Missouri, reached a $400,000 settlem
Midwest Women’s Healthcare Specialists in Kansas City, Missouri, reached a $400,000 settlem
APRIL 2, 2014
JUSTCODING
Bylaws serve as the governing documents of the medical staff. Bylaws must meet the hospital&rsquo
DECEMBER 13, 2013
As we update our Clinical Privilege White Paper library, I’m often amazed at how mu
JULY 23, 2014
JUSTCODING
JULY 30, 2014
JUSTCODING
Does your facility perform outpatient clinical documentation improvement (CDI) reviews?
SEPTEMBER 3, 2014
JUSTCODING
Does your facility perform outpatient clinical documentation improvement (CDI) reviews?
SEPTEMBER 10, 2014
JUSTCODING
SEPTEMBER 24, 2014
JUSTCODING
  A clinical learning environment review (CLER) visit to your facility is imminent
SEPTEMBER 12, 2014
by Deepak Gupta, MD, anesthesiology clinical assistant professor, Wayne State University, Det
AUGUST 26, 2020
MARCH 9, 2017
Many coders rely on the AHA's Coding Clinic advice to resolve sticky situ
MAY 13, 2015
JUSTCODING
Written by Renee Kinder, MS, CCC-SLP, RAC-CT, Director of Clinical Education at Encore Rehabi
Hazards posed by batteries and alcohol preps prompt a review of fire safety issues in clinics
Julie comes into the Fix ‘Em Up Clinic with a seriously broken arm. Her son Jay left his to
Documentation of terminal illness at admission and during the hospice service period must be deta
Documentation of terminal illness at admission and during the hospice service period must be det
Jeff, an 18-year-old male, came into the Fix ‘Em Up Clinic with complete left oculom
Compliance MSPs, physicians, and hospital-owned clinics:
Q: Is there an industry standard metric goal for CDI specialist reviews of Medicare cases?
by Deepak Gupta, MD, anesthesiology clinical assistant professor; and Sarwan Kumar, MD, inter
JUNE 23, 2017
  Have a question? Need to find a document? Not sure where to look? Watch this site demo now!
JANUARY 19, 2017
CMS issues 2014 annual update for Clinical Laboratory Fee Schedule and Laboratory Servi
The popularity and growth of retail medical clinics and pharmacies continue to increase. And now
JUNE 18, 2015
  CMS is rolling out the next version of Transforming Clinical Practice Initiative Support and
Can the plan of care serve as a way to document medications?  
By Julie Mills, RN, MBA, senior manager, clinical solutions executive, PerfectServe
JANUARY 28, 2020
In addition to documentation by physicians, nurses’ documentation affects patient safety,
JANUARY 8, 2020
What documentation is necessary for a medication review? The regulation
  In 2019, primary care physicians earned an average of $237,000 and specialists ear
APRIL 12, 2019
The National Practitioner Data Bank (NPDB) Final Regulations define clinical privileges as &ldqu
How many case managers and visit nurses do you recommend per clinical manager?
SEPTEMBER 24, 2014
JUSTCODING
DECEMBER 3, 2014
JUSTCODING
Effective documentation of the condition and the patients’ co-morbidities may help lawyers
In December 2014, CMS posted a document on its Advisory Panel on Hospital Outpatient Payme
HCPro is seeking feedback on your rural health clinic billing and compliance training needs. Plea
MARCH 26, 2014
JUSTCODING
Medical staffs across the country are discovering their governance documents are inadequate for t
SEPTEMBER 30, 2015
JUSTCODING
Coding Clinic's Fourth Quarter 2013 issue focuses considerable attention on ICD-10-
In this pre-conference session, HCPro regulatory specialist Debbie Mackaman, RHIA, CPCO,
New timeframe for response to additional documentation requests  
The number of retail health clinics in the U.S. continues to increase at a rapid clip along with
Become more proactive. You no longer can wait for face-to-face documentation to arrive within sev