In many ways, CDI efforts in the critical access hospital (CAH) setting mirror the typical duties of those working in the short-term acute care world. Just ask specialists to identify their top documentation trouble spots.Read More »
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 »
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 »
ACDIS is proud to celebrate the 3,000th Certified Clinical Documentation Specialist (CCDS) credential holder, Rhonda Bisby, RN, BSN, CCDS, CDI specialist at Memorial Hermann Health System in Houston, Texas.Read More »
There are plenty of opportunities for new pediatric CDI programs to make a difference, but identifying those top query prospects can be difficult, says Karen Bridgeman, MSN, RN, CCDS, CDI educator, at the Medical University of South Carolina (MUSC) in Charleston.
Development of an effective CDI program can only be achieved by tailoring the program to the unique needs of each organization. This discussion focuses on some factors that CDI managers may need to reassess or establish, regardless of whether they are...Read More »
by Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC
In my experience, providers appear overwhelmed the moment you mention ICD-10-CM education. So, maybe we can disguise our education in the form of improving clinical documentation now. The following are examples of a few areas...Read More »
It’s been nearly two years since AHIMA joined ACDIS to offer the industry physician query instructions in Guidelines for Achieving a Compliant Query Practice, published in February 2013. Nevertheless, “there are a lot of myths and misinformation about query practices out there,” says...Read More »
