In Coding
Mar 29th, 2019
Clinical documentation improvement (CDI) is a process that continually seeks to answer, “How best can maximize the integrity of the medical record?” Although the goal of CDI is always the same—to provide a complete and accurate picture of a patient’s medical condition(s) and the care they receives—the means to achieve that goal are often specific ...
In CMS
Sep 8th, 2016
Until the implementation of ICD-10, documentation improvement was seen as an inpatient process. Hospitals were keenly aware that imprecise or nonspecific clinical documentation could result in coding accounts that group to lower DRGs; and thus, less reimbursement. So, the Clinical Documentation Specialist role has become vital to ensure that the documentation in the medical record accurately ...
In MACRA
May 6th, 2016
Clinical document improvement (CDI) and revenue cycle management have never been more important to our physician practices. That was made very obvious during a webcast the Centers for Medicare & Medicaid Centers (CMS) held May 4, “Merit-Based Incentive Payment System (MIPS) Overview.” Practices that take CDI seriously, can ultimately earn up to 9 percent in ...
In Audit
Jul 1st, 2014
Queries (also know as clinical clarifications, documentation alerts, or documentation clarifications, among other names) are an essential component of any clinical documentation improvement (CDI) program. A query is a communication and education tool that prompts physicians to provide detail about under-reported conditions found in the medical record. Queries may address several documentation areas...
Jun 30th, 2014
Last week, AAPC member Laurie Johnson MS, RHIA, CPC-H, FAHIMA was invited to comment on her recently launched e-news series covering clinical documentation improvement. “I began this series because I thought that there was a real need to focus on clinical documentation improvement by service line” said Laurie. She referred to the latest ICD-10 delay ...