ICD-10 Readiness Checklist

67, 66, 65, 64 days and counting…. We are officially on the FINAL countdown to ICD-10 implementation. Health systems, providers, payors, etc., are working diligently to review that “Master Task List” we all created, what seems to be, a decade ago by now. At this point, time is short and some in the healthcare industry […]

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Combination Code Support by CDI

As we continue our journey towards ICD-10 implementation on October 1, 2015, the use of combination codes brought up a discussion between myself and another CDS (Clinical Documentation Specialists). I had just read this  article , and we were doing some chart review and code capture in ICD-10, when we saw the combo code that was […]

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The paradigm is shifting

I was reading an article today about healthcare reform and the affordable care act, which linked an increase in CDI staff with the increased use of electronic health records. I began to reflect on the past 10+ years in the Clinical Documentation Integrity field. We have gone from just looking for a single opportunity to move […]

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Note Bloat

Electronic health records continue to be instituted within hospitals in order to more efficiently capture the documentation of the patient story. In a recent article “Clinical Documentation in the 21st Century” we hear the position of the ACP (American College of Physicians) , “The clinical record should include the patient’s story in as much detail as is required to retell the story.” This short statement appears simple but leaves a lot of interpretation and unknown to […]

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