Health Information Management

News: ACDIS White Paper examines the use of information from previous encounters for documentation clarification purposes

CDI Strategies, October 1, 2015

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The electronic health record has been a game-changer for CDI specialists, automating review processes, alerting providers to queries, and tracking physician responses. However, the new technology brings challenges as well. Cut and paste. Note bloat. The list goes on.

One of the biggest concerns is determining when to pull information from prior encounters when querying the physician. Some say it is fine, while others feel it goes against coding and other guidelines.

Which is why ACDIS leadership and its Advisory Board created a comprehensive white paper, reevaluating the role of the CDI specialists in physician queries and the use of prior information.

The six-page document examines whether to use information from a prior stay in order to clarify a diagnosis in the record, in light of new technologies and changes wrought by healthcare reform. 



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