New CDI Chart Reviews

A recent Q&A around how to review a chart by a CDI reminded me that so much has changed since 2005 when I began my adventure into the world of Clinical Documentation Improvement (CDI). The move from reimbursement first and foremost to accurate documentation has been such a turning point. The introduction of the Electronic Medical Record […]

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DRG Mismatch

DRG Mismatch: the buzz word for how well the Clinical Documentation Improvement department and the Inpatient Coding department are coming to the same conclusion on the appropriate codes applied to the medical record. It has been discussed amongst many in the industry that an appropriate benchmark of program success is based on the percentage of […]

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Query Appropriateness

A recent Q&A featured in ‘CDI Strategies’ April 16, 2015, caught my eye as it was about the appropriateness of putting certain information in a query. They talked about the rationale behind including mentions of Severity of Illness (SOI) and Risk of Mortality (ROM), as well as support for the level of care for the patient. I agreed […]

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Outpatient CDI Readiness

The talk of Outpatient CDI has been going on since the fall of 2014 as we began to understand more about the impact of ICD-10 on the outpatient environment. Although the CPT codes will not be changing, the need to capture the correct ICD-10 code for the diagnosis warranting the outpatient encounter is key. ICD-10 PCS will […]

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To Query or Not to Query?

As I read this blog about “ when to query ”, it reminded me that there is no time like now when it comes to accurate, complete and compliant queries. With the evolving Electronic Health Record (EHR) it has become more important to query as soon as possible in order to get the documentation complete and accurate. We […]

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CDI….. Clinical Documentation Improvement or Clinical Documentation Integrity or both?

The term ‘Clinical Documentation Improvement’ has been around for many years and described the early work of the reasoning behind the program’s start. The early implementation of CDI programs were sold to CFOs (Chief Financial Officers) as a way to increase their revenue stream around opportunities that were being left on the table by providers. […]

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