CDI - ICD10monitor

New hybrid CDI program blends off and on-site CDI operations. University of Pittsburgh Medical Center (UPMC) is a world-renowned healthcare provider and insurer based in Pittsburgh, Penn. that has 80,000 employees in the state. UPMC operates more than 30 academic, community, and specialty hospitals and more than 600 doctors’ offices…
Risk adjustment has been used to entice payers and providers to accept patients with multiple chronic conditions along with those patients who are relatively healthy. Is coding and billing for risk adjustment really any different than what we have been doing all along? It is different in that the codes…
Strive to achieve coding compliance that really works. I’m often asked about how one would or should strive for coding compliance and make it happen. The first thing I do is to identify and acknowledge the risks or potential risks that occur. We all know that there are risks across…
Eight steps to create a physician advisor system. The physician advisor (PA) role has become more commonplace over the last decade, with an increasing number of hospitals and health systems turning to PAs to assist with a variety of issues, such as supporting clinical documentation integrity (CDI), ensuring compliance with…
CDI, when properly performed, supports the ancient physician oath, “First, do no harm.”  Clinical Documentation Improvement Specialists(CDISs) play a vital role in the overall scheme of healthcare delivery through affecting measurable meaningful improvement in the quality, completeness, and accuracy in the telling of the patient story. The major beneficiaries of…
An inspiring story about rebranding a facility’s CDI department To raise a torch to the strength of women working in healthcare I must share an introductory story on the transformation of a revitalized CDI Department that has pursued success through the strength of 23 women, and the celebrations are taking…
Physician documentation issues during an audit go beyond CDI. The issues are the chief complaint and HPI. Editor’s Note: This is the second piece in a four-part series that examines physician documentation issues as seen by an auditor. As I discussed in the first portion of our series on physician…
Physician documentation issues during an audit go beyond CDI. EDITOR’S NOTE: This is the first in a four-part series that examines physician documentation issues as seen by an auditor. One of the services I offer, aside from coding and billing education, is practice audits for evaluation and management (E&M) procedural…
Ten strategies for avoiding burnout are provided by the author. On any given day, if you walked into my home office, you might think you were in a spa. The walls are painted a soothing aqua color (at least, I think it’s soothing), a scent diffuser releases a pleasant tea…
Each patient’s story should be told in the official record. The clinical documentation integrity (CDI) profession has only scratched the surface of instilling positive change in patterns of physician documentation and communication of patient care. There exists a myriad of opportunities for CDI specialists to capitalize upon and truly improve…