Medical breakthroughs. Evolving health insurance legislation. The transition to ICD-10 . Change is a constant in the field of medical coding – driving demand for experienced coders with relevant industry certification.
Category: Clinical Documentation Improvement (CDI)
The Effective Query Checklist In recent times, there has been much emphasis placed on developing a compliant query and for good reason.
Standardizing Audit Feedback to Enhance the Outpatient Educational Process Lynn Thornton, RHIA, CCS MedPartners Education and Compliance Manager There is no doubt the auditing process is a valuable endeavor that helps drive correct coding, optimize reimbursement and satisfy coding compliance efforts.
Fourth Universal Definition of Myocardial Infarction (UDMI) CDI & Coding Considerations for Myocardial Injury Studies have shown that myocardial injury, defined by an elevated cardiac troponin (cTn) value, is frequently encountered clinically and is associated with an adverse prognosis.
How to Review a Record: One Document at a Time I subscribe to an encounter-driven review, where one follows the provider’s critical thinking process during the encounter.
Simplifying Clinical Validation There are many definitions for clinical validation (CV), but in healthcare, clinical validation is ensuring clinical evidence exists in the medical record for all documented diagnoses/conditions.
The Importance of Continued Education for CDI Professionals When it comes to the clinical documentation improvement (CDI) field, it’s important to remember that learning doesn’t start and stop in the classroom.
How Can I Launch a Career in Clinical Documentation Improvement? Are you a healthcare professional looking for a change? You may be surprised to learn that many clinical documentation improvement (CDI) specialists come from a variety of healthcare professions, including health information management (HIM), physician and nursing, coding, and clinical and administrative backgrounds.
Patient Safety Indicators In 2000, following publication of the Institute of Medicine’s groundbreaking report To Err Is Human, the Agency for Healthcare Research and Quality (AHRQ), was called upon to develop a standardized approach to identifying and reporting patient safety issues.