Jera Van Damme, BSN, RN, CCDS, is a senior clinical documentation educator at Essentia Health in Duluth, Minnesota, a member of the Minnesota ACDIS Chapter, and a member of the ACDIS Forms & Tools Library Committee.Read More »
The evaluation and management (E/M) section of the Current Procedural Terminology (CPT®) manual is divided into broad categories such as office visits, hospital visits, and consultations. E/M code assignment consists of seven...Read More »
by James S. Kennedy, MD, CCS, CDIP, CCDS
Many hospitals find that their patient safety indicator (PSI) ratios remain high despite doing a spectacular job of addressing these events and exclusions.Read More »
By Anny Yuen, RHIA, CCS, CCDS, CDIP, and Page Knauss, BSN, RN, LNC, ACM, CPC, CDEO
In many instances, the documentation for a particular service needs to be provided before the encounter. This is especially true for diagnostic tests such as MRI scans.Read More »
By Howard Rodenberg, MD, MPH, CCDSDo you ever wonder if your professional skills are actually useful in the real world? I know I do. My resume as an emergency physician falls apart when applied outside of the ED, where it turns out you’re not allowed to stare at someone writhing on the...Read More »
Many organizations have HCC tools built into their CDI software or EHRs that can help them capture HCCs. When providers click on a diagnosis or a condition, the tool will mark whether the diagnosis is an HCC. Other technology can extract pharmacy data, lab data, other diagnoses, and the problem...Read More »
Even if the treating physician does not immediately document “acute respiratory failure” in the pediatric patient’s record, looking for specific wording and indicators can help support a CDI query to bring that diagnosis in—provided it is appropriate for that patient during that encounter.Read More »
