Many facilities employ CDI specialists as frontline educators for physician ICD-10 documentation training. Post-implementation, they rely on CDI staff for continuing education efforts. Any number of continued training tactics may prove successful. One such an approach incorporates documentation...Read More »
Though many coders and auditors say so, there is no official direction that states diagnoses can only be reported if they’re included in the discharge summary. We teach in our CDI Boot Camps that, although it’s desirable if the...Read More »
Those who’ve been in CDI long enough remember the days of colored paper queries slipped into charts. Often, those queries would get lost in the literal shuffle, or simply go unanswered and ignored with no concrete way of tracking the query. Then, electronic health records (EHR) came on the scene...Read More »
Editor’s note: Cesar M. Limjoco, MD, and Kelli A. Estes, RN, CCDS, will be presenting “The ultimate test for queries,” on Day 1 of the ACDIS conference. Limjoco is the vice president of DCBA, Inc. in Indianapolis, Indiana....Read More »
The use of electronic health records (EHR) should be guided by ethical principles that put patient care at the forefront, according to a position paper published by the American College of Physicians (ACP). EHRs can be an...Read More »
Q: Lately, we have been receiving responses of “did not assess or treat” or “this is a chronic stable medical problem not associated with the patient’s presentation,” although the nutritional assessment such as severe malnutrition is...Read More »
