The clinical documentation improvement (CDI) vendor landscape has undergone significant changes over the last couple of years, including vendor acquisitions and technology developments. And these changes and other factors have had an impact on customer experience, according to a recent KLASÂ report. For example, vendors like Iodine, Optum, and 3M have gained momentum over the past […]
One billion dollars is a big number, but more astounding to me, as it pertains to a recent finding by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), was that hospitals were found to have incorrectly documented and/or coded severe malnutrition 86.5 percent of the time (173/200)! That’s almost […]
Case study proves the need for physicians to be members of the CDI team. Having a strong denials management team is critical for facilities. If providers do not leverage proper resources to generate strong appeal letters, the third-party payers will uphold their decisions to remove or change diagnosis or procedure codes. This usually will lead […]
Tips for improving outpatient billing, coding and CDI. In moving from inpatient clinical documentation improvement (CDI) to outpatient CDI, I have been discovering some unique educational pointers. I know we are all very busy, so let’s just dive right into it. Doctors and coders, you should not have diagnoses that are mutually exclusive to one […]
88% of providers are eager to implement clinical document improvement technology that leverages AI, and 93% believe the systems can streamline document creation. Forty-four percent of healthcare organizations already use artificial intelligence (AI) in one form or another, and more hospitals are looking to apply the technology to coding and clinical documentation improvement, a recent […]
Over my almost 30-year surgical coding career, the documentation for assistant surgeons consisted of only the name of the assistant surgeon in the operative note header. Most often there was no mention of the role of the assistant surgeon in the body of the operative note; it was assumed the assistant surgeon provided an extra […]
Complications of chronic kidney disease (CKD) include early death and heart disease. Chronic kidney disease (CKD) affects 15 percent of United States adults, or 37 million people, according to a recent statement by the Centers for Disease Control and Prevention (CDC). The following are some basic facts about CKD; specifically, it is: More common […]