Asking CDI professionals with an RN licensure, but without a coding credential, to also code the medical record may not only lead to noncompliant (and potentially erroneous) code assignments, but also harm the delicate working balance between the HIM/coding department and the CDI staff.Read More »
CDI and coders alike will probably have the most difficulty when it comes to using the new ICD-10-PCS codes.CDI staff need to learn what information the coding staff needs to correctly code a chart. Coding Clinic for ICD-10-CM/PCS, Third...Read More »
Over the years we've collected a number of interesting and fun CDI-related holiday memes. We thought we'd share a few of them here as our featured article to help you celebrate the season.
CMS scours all claims it processes for eligible discharges for the pneumonia readmission measure. Every discharge that meets defined requirements counts regardless of whether the discharge resulted in a readmission. These eligible discharges are then...Read More »
Many clinical documentation improvement (CDI) specialists with clinical backgrounds are encoder dependent, trained to “code” using an encoder and taught to create a working MS-DRG based on grouper software. Many coders also rely on the...Read More »
To understand how to appropriately assign codes for chronic kidney disease (CKD) and acute kidney injury (AKI), instead of just reporting the codes that correspond with each and every note in the record, coders need to take a closer look at the clinical...Read More »
The incidence sepsis cases within the United States has quadrupled while the length of stay of these cases and the mortality has decreased. And Recovery Auditors have denied numerous claims because, at least in part, CDI staff queried to get sepsis DRGs when...Read More »
ICD-10-CM/PCS requires increased specificity in the clinical documentation to support that specificity in coding, says Bonnie S. Cassidy, MPA, FAHIMA, FHIMSS, RHIA, AHIMA-approved ICD-10 trainer, senior director of HIM innovation at Nuance Communications headquartered in...Read More »
