It’s Complicated: Post-Operative Complications
Oct25

It’s Complicated: Post-Operative Complications

The challenge for clinical documentation improvement specialists is in determining if the condition is an expected outcome of the procedure or patient’s disease process, or if it is an actual post-operative complication.

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MDS Coordinators and Informatics: Own Your Expertise
Sep28

MDS Coordinators and Informatics: Own Your Expertise

The minimum data set (MDS) coordinator is a key player in a skilled nursing facility’s (SNF’s) team.

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Time for a Health Check on Physician Queries: How Mobile Technology Can Modernize CDI
Aug28

Time for a Health Check on Physician Queries: How Mobile Technology Can Modernize CDI

Hospital billing is complex and accuracy is critical, as it can affect not only reimbursement, but hospital and physician quality scores as well.

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Risk Adjustment Strategies in the Outpatient Setting: From Concept to Capture
Jul31

Risk Adjustment Strategies in the Outpatient Setting: From Concept to Capture

As the current healthcare paradigm continues to shift to value-based care models with an outpatient emphasis, addressing outpatient clinical documentation is prudent.

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Moving Beyond Diagnosis Codes in CDI: Documentation Improvement for CPT
Jun28

Moving Beyond Diagnosis Codes in CDI: Documentation Improvement for CPT

Just as ICD-10-CM codes are used to translate clinical diagnoses into codified language, CPT codes identify diagnostic and therapeutic procedures and services using a systematic five-digit code.

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Much Ado About Query Rate
May23

Much Ado About Query Rate

While the use of queries is an essential tool in a CDI program, it is possible for an undue emphasis on “query rate” to lead to misuse of this important tool.

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