Now that ACDIS Annual National Conference has concluded, this is an excellent time to revisit and potentially revise and revamp our current clinical documentation improvement initiatives. Clinical documentation improvement, while considered a service business, is quite similar to most other product lines in the sense of finite and distinct end point life cycles. Take automobile […]
An article in the Fierce EMR daily newsletter titled EHR Fraud: A Slippery Slope caught my attention, not because electronic health records have the potential to perpetuate fraud, but for the fact EHRs potentially promote abusive coding and billing Consider the templates and “ease of use” structured drop down menus, not to mention wide spread, […]
Harnessing the power of the discharge summary – www.hcpro.com.
Ensuring clear and concise documentation critical for case managers – www.hcpro.com.
The second of a series on CDI for physicians titled CDI and Medicine- A Synergistic Approach is available on the QuantiaMD website. QuantiaMD.com. Clinical documentation improvement is not only of material benefit to the hospital, there is tremendous value to the physician as well as patient in adhering to best practice standards of effective […]
CDI-Tremendous Unrealized Potential
Clinical documentation improvement programs can potentially serve a wide array of beneficiary purposes besides improving revenue capture and optimization if offered the opportunity. Present initiatives at documentation specificity, while inarguably important and valid under ICD-10 processes, are primary limited to basically scratching the surface when compared to the tremendous unrealized potential we as […]
Clinical Bundles
Bundles of care exist for serious disease processes with tendencies toward greater mortality rates such as sepsis. These bundles consists of standard checklists of care interventions that have demonstrated increased efficacy in overall treatments that are cost effective, efficient, drive notable decreases in morbidity and mortality while improving the cost and value equation of […]
My recent blog posts on clinical documentation improvement programs have outlined the real limitations of present CDI initiatives, serving as significant barriers to achieving optimal potential. I had the opportunity to review an established CDI program for purposes of identifying potential areas ripe for process improvement and/or expanding of CDI staff present core competencies and […]
The term “Clinical Documentation Improvement” is synonymous with impacting case mix index and CC/MCC capture clinical specificity. Does Clinical Documentation Improvement equate to achievement of effective clinical documentation. Are the terms synonymous, mutually exclusive or synergistic in nature?
Clinical documentation improvement specialists should be striving to achieve in each and every chart we review complete, accurate […]
ICD-10 Training and Preparation- The Success Factor
The delay in implementation of the ICD-10 classification system is not likely to continue in 2015 with many associations including AHIMA and nearly 100 other physician driven associations offering their support of ICD-10 this time around. Forward thinking providers are beginning to ramp up their preparation and training plans […]