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Computer Assisted Coding - Project & Change Management Success!

Computer Assisted Coding (CAC) continues to be a Coding and Clinical Documentation Integrity (CDI) industry hot topic, as the logical next step in resource containment and the focus on quality improvement. Today’s burning platform is to thrive in the [...]

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Mind the Gap: Bridging the Coder-Clinician Relationship for Gains

Here at The Wilshire Group, we take pride in bringing resources together and navigating multidisciplinary areas to achieve optimal workflow and revenue cycle results. Last week we provided some ideas around CDI (clinical documentation integrity), and [...]

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What’s the Hype?…Outpatient Clinical Documentation Integrity

In last week’s blog: Evaluation and Management (E/M) Essentials, we mentioned aligning coding educators with clinical build experts to support a foundation for accurate coding and charge capture success. Undoubtably, such an education and feedback [...]

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Combination Code Support by CDI

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 [...]

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Technical CDI systems are only successful if utilized appropriately

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 [...]

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Well-defined and understood processes and policies are key to an efficient and effective CDI program

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 [...]

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New CDI Chart Reviews

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 [...]

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DRG Mismatch

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.

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Case Mix Index (CMI)

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. [...]

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Query Appropriateness

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 [...]

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