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The Privacy Mindset with Third Party Record Reviewers

As HIM professionals we expect others we encounter in our personal and professional lives to share our same high level of commitment and dedication to our professional career.  We also expect that from our team at the office, including external third-party auditors and record reviewers. External reviewers must share your organization’s commitment to protecting patient […]

ROOT OPERATION DILEMMA: CONTROL vs. DESTRUCTION

A 67 year old male who had been experiencing frequent melena presents to the hospital for work up and treatment. An esophagogastoduodenoscopy (EGD) was performed with the finding of a medium sized angioectasia (AVM) seen in the mid jejunum which was thought to be the source of the bleeding.  As a result, the following procedure […]

2017 HIM Challenges in Data Integrity, Revenue Integrity & Denial Prevention

As we evolve in 2017, the challenges have settled for Health Information Management (HIM) post implementation of ICD-10.  Clinical Documentation Improvement (CDI) programs and Computer Assisted Coding (CAC) continue to bring value to data integrity.  Larger healthcare systems continue to centralize revenue services while their auditing efforts have improved with technology and resources to conduct […]

Insight into Coding Diabetic Eye Conditions

There are a variety of conditions that can impact individuals with diabetes.  People with diabetes are at greater risk for developing eye problems that could lead to blindness or serious deterioration of sight.  Age also plays a role in the progression of eye disease in individuals with diabetes.  Cataracts, glaucoma and retinopathy are the most […]

The Evolving Landscape for Health Information Management

What are the most significant challenges for Health Information Management (HIM) departments?  One of the challenges in 2016 includes the disappearing HIM department; physical downsizing as well as workforce downsizing.  With the workforce downsizing we see technology impacting traditional roles for transcriptionists, documentation specialists and coders. HIM professionals need to manage business, clinical and information […]

Face-to-face Interactions: The Missing Link In CDI

  Remote Clinical Documentation Improvement Coding There’s no doubt that remote work has its perks for employers—increased productivity, lower overhead costs, and a better pool of candidates from which to choose. We explored the benefits of remote work options in a recent blog topic here. However, in a virtual world, the nuances of good old […]

Top 3 Reasons to Implement an Outpatient CDI Program

Although CDI programs have typically been implemented in the inpatient setting, many organizations are beginning to turn their attention toward outpatient documentation as well. That’s because many of the same documentation deficiencies occur in both settings. Poor outpatient documentation—particularly in the emergency department (ED) record—can also affect inpatient code assignment. As third-party auditors continue to […]

MRA Thought of the Day – The Stakes Are High for a Successful CDIP

Situation: The multitude of changes in the healthcare industry are forcing hospitals to re-design and re-energize their Clinical Documentation Improvement Programs. To assist in this endeavor, HIM Directors and coding managers should examine the existing relationship between the two driving forces behind the success of the CDIP. Regardless of whether it appears the HIM coders […]