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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Business Email Etiquette

Even in the dozen years or so that I’ve been working, electronic communication has changed so much. We are all on the go, and it’s common that a lot of email is done from phones & tablets; maybe even more so than laptops. With this comes a tendency to make communication more casual, and the […]

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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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