Computer Assisted Coding

CDI Can Help Reduce Medical Errors

By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM for ICD10 Monitor CDI, when properly performed, supports the ancient physician oath, “First, do no harm.”  Clinical Documentation Improvement Specialists(CDISs) play a vital role in the overall scheme of healthcare delivery through affecting measurable meaningful improvement in the quality, completeness, and accuracy…

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Auditing Issues Uncovered in Physician Documentation: Part III

By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor Is your Electronic Medical Record (EMR) system helping you pass an audit or hurting you? Editor’s Note: This is the third piece in a four-part series that examines physician documentation issues as seen by an auditor. Click here…

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Auditing Issues Uncovered in Physician Documentation: Part II

By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor Physician documentation issues during an audit go beyond CDI. The issues are the chief complaint and HPI. Editor’s Note: This is the second piece in a four-part series that examines physician documentation issues as seen by an auditor. Click here…

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It’s not just EHRs: Interoperability also poses big challenges for revenue cycle

By Mike Miliard for Healthcare IT News More than three-quarters of the hospitals surveyed for a new HIMSS Analytics study said that denials are the biggest challenge they face with revenue cycle management. One reason for that could be their use of multiple IT systems that don’t mesh well together with various systems looking at…

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Feeling the Burn: Confessions of a Formerly Burned Out Coder

By Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer for ICD10 Monitor Ten strategies for avoiding burnout are provided by the author. On any given day, if you walked into my home office, you might think you were in a spa. The walls are painted a soothing aqua color (at least, I think it’s soothing),…

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In Outpatient CDI, Timing is Everything

Article by Susan Richards Morgan, CCS, CPHQ, CPC, CDEO, CRC, CPMA, CEMC, CPC-I. This article was originally published on the A Journal of AHIMA Blog on April 25, 2018 and is republished here with permission. Currently, most clinical documentation improvement (CDI) programs have been developed inside hospitals with an inpatient focus. Medicare generally expects an inpatient admission to need two…

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Auditing Issues Uncovered in Physician Documentation: Part I

By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor Physician documentation issues during an audit go beyond CDI. EDITOR’S NOTE: This is the first in a four-part series that examines physician documentation issues as seen by an auditor. One of the services I offer, aside from coding…

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