While writing policies and procedures often seem to be time-consuming and a challenge, they have many positive benefits that cannot be overlooked. For Clinical Documentation Integrity (CDI) program having written policies and procedure is part of compliance and the day-to-day operations of the CDI staff. When we think about written policies and procedures (P&Ps) we often...

Within Clinical Documentation Integrity (CDI) and clinical Coding we have verbal, written and electronic documentation clarifications or querying. A key component of the clinical documentation query is achieving and maintaining compliance. Having a written policy and procedure in place along with a formal quality review process for querying is thus essential and a must. ...

The words “Hierarchical Condition Categories” or HCCs can conquer up some anxiety for HIM Coding, and Clinical Documentation Integrity (CDI) professionals, even for Revenue Cycle and Compliance leadership. Add to that, the word “audit” and we now have uneasiness and even fear. Well, it does not need to be this way. Understanding the HCC basics and the coding audit ins and...

Outpatient Clinical Documentation Improvement/Integrity is gaining more and more attention. Having a successful program involves preparation, planning and executive. As we discussed in Part I (in the previous RMC newsletter) there are several key components to an OP CDI program. A best practice is to identify one setting that you wish to focus your CDI program on to...

There are several cardiovascular diseases that contribute to death in the United States and also are the leading cause of death. According to the Centers for Disease and Control (CDC), 1 in every 4 deaths are due to heart disease. The most common cardiovascular disorder is coronary artery disease (CAD), and in fact a heart attack or myocardial infarction (MI) occurs every...

With more and more patient services moving to the outpatient setting we need to be ready and prepared for the implementation of an outpatient (OP) Clinical Documentation Improvement/Integrity (CDI) program. CDI has a strong footprint in the inpatient hospital setting where there are longer periods of time of patient interaction, longer time to review the health record and...

Heart failure is a serious medical condition that an estimated 5.7 million Americans are diagnosed with.  This is a condition that occurs when the heart muscle cannot pump enough blood and oxygen needed by the body to support the other organs.  According to the Center for Disease Control, the national estimated cost to treat heart failure is nearly $31 billion each year. ...

With the OCR issued FAQs on patient HIPAA rights to access PHI being out now for over a year, I know many of you are feeling more confident than ever on how to handle these pesky third party requestors who demand records under the HITECH Act. Or perhaps you are just as challenged as the rest of us? The FAQs clarified that individuals (patients according to HIPAA...

Overweight and obesity are increasingly common conditions in the U.S. They are caused by the increase in the size and amount of fat cells in the body. Doctors measure body mass index (BMI) and waist circumference to screen and diagnose overweight and obesity. The National Institute of Health has deemed obesity as a serious medical condition that can cause complications...

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 was performed: A single medium angioectasia...

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...

  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 common eye diseases that...

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...

Organizations did a fantastic job preparing for ICD-10. However, now that the dust has settled, we need to drill down into the data. Specifically, case mix index (CMI). With more than two months’ worth of ICD-10 data, it’s easier to make comparisons and draw logical conclusions. If coding and/or documentation problems exist, they’re likely starting to emerge through your...

Unfortunately, the silos between coders and CDI professionals still exist in many hospitals. In some organizations, the walls may be slowly coming down, but in others, the silos stand tall. The irony is these two roles actually have more in common than they might realize. With communication and collaboration, coders and CDI specialists actually have the power to make a...

As the ICD-10-CM/PCS deadline approaches, it behooves HIM professionals to remind CDI specialists and physicians about important components of a thoroughly-documented operative note. Such a note supports accurate code assignment for reimbursement, and it also provides an accurate record for continuity of care as well as quality initiatives and legal and research purposes.

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 fashioned face-to-face...

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...

Role changes are on the horizon for coding professionals. With the implementation of Computer Assisted Coding (CAC), ICD-10 and Hospital Value-based Purchasing (HVBP), clinical coding will take on different forms and new responsibilities. Traditional coding careers may transition to auditors, data analysts or even clinical documentation improvement / integrity specialists...

Situation: Lynn Salois, RHIT, CCS, CDIP, Director of Coding 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...