Okemena Ewoterai used to take a folder off a shelf and peer through the papers inside looking for hints—scraps of stories that could lead her to a better understanding of why a particular patient needed to be in her hospital. When she found them, Ewoterai would pull out a piece...Read More »
Queries are definitely not what they used to be. When I first started as a CDI specialist, back when dinosaurs roamed the earth, the query process was a muddy exercise in creative writing.Read More »
By Marion Kruse, BSN, RN, MBA, and Jennifer Cavagnac, CCDS
Every CDI program should objectively evaluate the outcomes, processes, and compliance of their CDI efforts. Auditing and monitoring provides oversight for the CDI program, insight into physician documentation and...Read More »
By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS
At the 2017 ACDIS conference in May, Nelly Leon Chisen, RHIA, director of coding and classification, the executive editor of the American Hospital Association’s (AHA) Coding Clinic ...Read More »
By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS
The 2017 Official Guidelines for Coding and Reporting, effective October 1, 2016, contained a new, perplexing, and problematic section I.A.19 titled “Code Assignment and Clinical Criteria,” which states:...Read More »
Q: We use an electronic system at our hospital, and find it is difficult to query a physician since we all have our own processes. Would you recommend having a set format for a query that is used electronically?
A: This is going to be contingent on the system your...Read More »
Nursing notes cannot be used for coding and billing purposes. This does not mean, however, that they’re worthless for CDI purposes. Often times, CDI specialists neglect reviewing this documentation because they know it can’t be coded. This is a mistake.
