Even on a small scale, knowing where to start with an outpatient CDI program implementation can leave leaders at a loss. Add in the complications of a large healthcare system and things can get even hairier. With multiple sites and teams dispersed geographically, there’s a lot to consider before...Read More »
by Tammy Trombley, RHIT, CDIP, CCDS
Recently, an outpatient CDI review project at a large family practice/internal medicine physician clinic identified numerous coding errors on physician-coded claims. More than half of the errors affected risk adjustment for the CMS-Hierarchical...Read More »
by William E. Haik, MD, FCCP, CDIP
Complex pneumonias such as Gram-negative bacterial pneumonias and aspiration pneumonias segregate to a higher-weighted MS-DRG (MS-DRGs 177–179 [Respiratory Infections and Inflammations]) than simple pneumonias such as Streptococcus pneumoniae...Read More »
by Sharme Brodie, RN, CCDS
The last quarter of the year typically includes a large number of items for the American Hospital Association’s (AHA) Coding Clinic for ICD-10-CM/PCS publication. This recent release doesn’t disappoint, with a whopping 94 pages worth of material...Read More »
Valerie Parent, RN, BSN, CCDS, CCRN-K, is employed with Norther Light Health as the CDI manager at Eastern Maine Medical Center in Bangor, and is the leader of the Maine ACDIS chapter. Parent has held her CCDS credential since 2015.Read More »
by Cheryl Ericson, RN, MS, CCDS, CDIP and Cathy Farraher, RN, MBA, CCM, CCDS
Clinical validation is a process in which diagnoses already written in the chart are reviewed by a clinical documentation specialist to ensure the corresponding clinical indicators and treatment exist...Read More »
by Tracy Boldt, RN, BSN, CCDS, CDIP, and Ellen Jantzer, RN, MSN, CCDS, CCS, CRC
The rules of compliant query practice do not change based on the setting. We must consider query construction and wording of provider communication with the same eye for compliance as we have...Read More »
