Clinical Documentation Archives

CDI and Compliance: The Offense of Being Naked

Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC November 14, 2022

Diagnosis without supporting the judgment of the physician’s documentation is the phenomenon of nakedness. A recent Association of Clinical Documentation Integrity Specialists/American Health Information Management

Are Leading Queries Prohibited by Law or Lore?

Erica E. Remer, MD, CCDS October 10, 2022

AHIMA released its CDI Practice Brief Monday. At Yom Kippur services, I found myself thinking about the question Dr. Ronald Hirsch posed to me the

AHIMA Releases New Guidelines for Queries

Chuck Buck October 10, 2022

The updated guidelines were developed jointly by AHIMA and ACDIS. The American Health Information Management Association (AHIMA), in collaboration with Simplify Compliance’s Association of Clinical

Struggling with Patient Safety Indicators? Help is Coming Your Way

Erica E. Remer, MD, CCDS October 3, 2022

A four-part series on PSIs is being produced by ICD10monitor and Talk Ten Tuesdays in cooperation with ChristianaCare. I bet some of you reading this

Nine Elements of an Effective CDI Program

Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC September 26, 2022

These foundational elements are essential to assure that there is a better way to improve CDI. Clinical Documentation Integrity (CDI) programs continue to evolve over

Tips for Preparing for New Coding Changes for 2023

Cheryl Ericson, RN, MS, CCDS, CDIP September 12, 2022

New codes become effective Oct. 1, 2022. With the start of fiscal year (FY) 2023 right around the corner, this is a good time for

Is Your CDI Program Putting You in the Danger Zone?

Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC August 15, 2022

Time for CDI checkup. Clinical Documentation Integrity (CDI) programs may be exposing hospitals to unnecessary, costly compliance risks and financial exposure by virtue of their

CDI: Documenting Diagnoses and Patient Safety

Cheryl Ericson, RN, MS, CCDS, CDIP July 25, 2022

Documenting a diagnosis in the health record extends beyond its impact on reimbursement and quality-of-care measures. It is also critical to patient safety. As a

Rebranding CDI Hasn’t Helped, Redirection Has

Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC July 18, 2022

Integrity or improvement? In too many programs there is very little improvement or integrity achieved within the medical record aside from enhanced capture of diagnoses

Putting the “Integrity” in CDI

Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC June 27, 2022

With unrelenting focus upon reimbursement within too many CDI programs, the opportunity to effectively improve the integrity of the medical record and its patient story

Pivoting CDI: The World of Healthcare Watches

Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC March 28, 2022

Is CDI about to embark on a long journey to reinvent Itself? There is no arguing that artificial intelligence (AI) and natural language processing (NLP)

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