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 [...]

In today’s technical world, CDI is dependent upon being able to capture the work and outcomes that are achieved by the processes and policies being followed by the staff. There are many CDI software vendors and systems on the market today. The choice is [...]

We all want to have efficient and effective Clinical Documentation Integrity programs. Well defined workflow processes are a key to achieving this goal. The time spent to do a review of current CDI program and/or map (Value Stream Mapping) out your [...]

A recent Q&A around how to review a chart by a CDI reminded me that so much has changed since 2005 when I began my adventure into the world of Clinical Documentation Improvement (CDI). The move from reimbursement first and foremost to accurate [...]

DRG Mismatch: the buzz word for how well the Clinical Documentation Improvement department and the Inpatient Coding department are coming to the same conclusion on the appropriate codes applied to the medical record.

I have been watching discussion on CDI-Talk about Case Mix Index (CMI) as well as an article in CDI Strategies, April 16, 2015. It reminded me that organizations' finance departments need to look at more than just CMI when predicting the future revenue. [...]

A recent Q&A featured in 'CDI Strategies' April 16, 2015, caught my eye as it was about the appropriateness of putting certain information in a query. They talked about the rationale behind including mentions of Severity of Illness (SOI) and Risk of [...]

After flying, layover, college graduation, family time, more flying, running through the airport to make a connection and finally getting on the flight to San Antonio for the annual ACDIS conference, I began to wonder what it is about my drive and thirst [...]

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 [...]

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 [...]