Below is a complete listing of all CDI articles that have appeared in JustCoding News.
June 18, 2013
The ideal approach to ICD-10-CM/PCS preparation is capitalizing on the synergistic partnership between clinical documentation improvement and coding professionals. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, discusses how organizations can use this dynamic to improve preparations for ICD-10.
June 11, 2013
Clinical documentation improvement (CDI) initiatives often focus on inpatient documentation to ensure that documentation accurately reflects patient severity. Laura Legg, RHIT, CCS, explains how CDI efforts can also benefit outpatient coding.
June 4, 2013
Any ICD-10-CM/PCS to-do list wouldn’t be complete without the task of reviewing and revising query templates. Cheryl Robbins, RHIT, CCS, Gloryanne Bryant, RHIA, CCS, CDIP, CCDS, and Sandra L. Macica, MS, RHIA, CCS, provide tips for updating queries for ICD-10.
May 21, 2013
CMS and auditors are increasing scrutiny of CCs and MCCs. William E. Haik, MD, FCCP, CDIP, provides tips that coders can use to look for clinical evidence in the record before querying for these targeted conditions.
May 7, 2013
The increasing complexity of the healthcare reimbursement system, quality initiatives, and the transition to ICD-10-CM/PCS put clinical documentation improvement programs in the spotlight. Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, discusses the importance of documentation improvement specialists.
February 26, 2013
Physician documentation must reflect severity of illness and risk of mortality for all patients. Robert S. Gold, MD, and Valerie Bica, BSN, RN, CPN, explain why pediatric patients require special attention in terms of clinical documentation improvement specialists.
February 26, 2013
Q: A patient presents with a sore throat, and the physician states “Sore throat; differential diagnoses include streptococcal sore throat, tonsillitis, postnasal drip.”
If the physician doesn’t rule out any of the differential diagnoses, should the coder query for clarification or simply choose one of the differential diagnoses?
January 15, 2013
Physicians, especially ED physicians, need to start paying attention to how their documentation affects the facility. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, and Bernadette Larson, CPMA, discuss how documentation in the ED affects medical necessity and inpatient coding.
January 15, 2013
Q: I’ve heard that queries differ between critical access and short-term acute care hospital settings. Is this true, and if so, where can I find more information?
December 4, 2012
ICD-10-CM/PCS incorporates laterality, acuity, anatomical specificity, and a slew of additional combination and complication codes. Who will submit queries when this information is missing in a medical record? Will coders or clinical documentation improvement specialists take on this role? Cheryl Ericson, MS, RN, CCDS, CDI-P, and Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA, offer suggestions for determining who will submit queries.