by Amy Czahor, RHIT, CDIP, CCS
Recently I was reviewing a data sample investigating the root cause of DRG discrepancies between CDI and coding. More than half of the cases with a discrepancy were attributed to a difference in principal diagnosis selection.Read More »
CDI specialists can pretty much come from any background in the medical field—from physicians, to nurses, to coders, and everything in between. While CDI specialists generally have the same day-to-day workflow (reviewing charts and sending queries), a specialist’s background prior to coming to...Read More »
by Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS
To limit exposure to claim denials and external reviews, the best safeguard for a facility is a robust, effective internal coding compliance policy, plan, and program.
Begin by reviewing any existing coding policies and...Read More »
The ACDIS Advisory Board created the following white paper which analyzes national survey data on CDI specialists' chart review productivity and lists the variables that can reduce or enhance that productivity. The white paper provides ACDIS’ recommendations on chart review productivity...Read More »
If at all possible, CDI programs should review all hospitalizations in a facility for documentation improvement opportunities. And all charts truly means every chart, including every insurance product, regardless of reimbursement mechanism (i.e., by MS-DRG or per diem), including the no-...Read More »
Probably the most onerous duty physicians have is the preparation of the inpatient discharge summary, especially after a long or complicated hospital stay. To be frank, I hate doing discharge summaries. I’ll find every reason to put them off. If I look at the current medical records delinquency...Read More »
The long-anticipated ICD-10-CM Official Guidelines for Coding and Reporting for fiscal year 2017 were released earlier this month, and include a definition for Exclude 1 notes, guidance for meaning and application of the word “with,” and clarification for laterality, according to an...Read More »