Ask pediatricians to consider the following documentation opportunities when writing their history and physicals (H&P), consults, progress notes, and discharge summaries, focusing on conditions present at the time of admission.Read More »
If your CDI program needs physician engagement ideas, perhaps tuning into the efforts at your nearby pediatric hospital can help—or, you can just call on Valerie Bica, RN, CPN, CDI specialist at Nemours/A.I. DuPont Hospital for Children in Wilmington, Delaware, and her teammates. Although many...Read More »
Out of habit, many physicians simply will not write the word encephalopathy, says Paul Simmons, MD, Assistant chief medical officer (CMO) and CDI physician advisor at Massachusetts General Hospital in Boston. For other doctors, words like encephalopathy, AMS, and delirium are all synonymous.Read More »
Are records with only one MCC noted targeted by Recovery Auditors or other audit agencies? I am confused because I have also heard that it’s good to capture one MCC.Read More »
The CDI specialist’s role is changing. It’s no longer enough to query for diagnoses and report corresponding codes. The diagnosis must be backed up by clinical indicators and thorough documentation—or it risks being overturned by an auditing agency. Read More »
The role of CDI programs grew out of the coding specialty. Knowledge of coding practices is a very important skill for the CDI specialist. CDI specialists do need to understand the basic tenets of code assignment, and follow the rules and regulations governing the coding process.Read More »
Formerly the vice president of the North Carolina ACDIS chapter, Brenda A. Harris, RN, CCDS, CCA, has worked in the CDI field for 12 years; she currently is a CDI specialist with Carolinas HealthCare Systems: Carolinas Medical Center University in Charlotte, North Carolina.Read More »
We’re just about six months away from the implementation of ICD-10 CM/PCS, and the AHA Coding Clinic for ICD-10-CM/PCS is rolling right along with advice for the new code set. ICD-10-PCS will be the greatest challenge facing coders this October, so the First Quarter 2015 edition focused...Read More »
