CDI

CDI in the Outpatient Setting: Finding the ‘Hidden Gems’ of Opportunity for Improvement

By Kay Merriweather, RHIA, CCS, CCS-P, COC, CHDA, CDIP; Leslie Slater, RHIA, CCDS, CIC, CRC; and Michele Bohley, RHIA, CCS for AHIMA “If it’s not documented, it wasn’t done.” This is one of the first axioms health information management (HIM) professionals learn. HIM professionals have witnessed the evolution of quality documentation, with patient education becoming…

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Has CAC Lived Up to Its Promise? Providers, Vendors Weigh In

Article by Lisa A. Eramo, MA. This article was originally published on the Journal of AHIMA website on June 1, 2017 and is republished here with permission. In the months leading up to the ICD-10 go-live, many hospitals implemented computer-assisted coding (CAC) in the hopes that it would offset anticipated productivity losses and boost coding accuracy. Now…

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Dolbey to Offer Physician Query Mobile App for CAC and CDI with Artifact Health

Dolbey’s award winning Computer-Assisted Coding application and new Clinical Documentation Improvement offering will now include the power and convenience of mobile physician queries and enhanced query management and reporting through Artifact Health. Dolbey’s Fusion CAC™ is deployed in the medical coding process.  Fusion CAC evaluates the patient chart documentation to suggest diagnostic and procedure codes…

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To Query or Not to Query? That Is the Question

Article byHarvey Bair, RN, PhD, CCDS, CRC. This article was originally published on the Journal of AHIMA website on April 28, 2017 and is republished here with permission. Do you find yourself wondering what to focus on when querying for ICD-10 specificity? Are you concerned that your organization’s query process may overwhelm providers? You are not alone; the…

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Dolbey, Maxim Partner to Offer RCM Services: 3 Things to Know

By Kelly Gooch for Becker’s Hospital CFO Computer software company Dolbey partnered with health information management and revenue cycle management services provider Maxim Healthcare Services. Here are three things to know about the partnership. 1. Through the partnership, Dolbey customers will be able to access Maxim’s staff for auditing, clinical documentation improvement, coding and other…

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Evolving CDI Roles Support Quality Across the Care Continuum

Article bySteven Robinson, MS, PA, RN, CDIP. This article was originally published on the Journal of AHIMA website on February 2, 2017 and is republished here with permission. The role of a clinical documentation professional  is increasingly critical to improved patient outcomes.  Clinical documentation improvement (CDI) concurrent review efforts result in better accuracy of severity of illness and…

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Top Takeaways From the 2016 AHIMA Convention

Article by Mary Butler. This article was originally published on the Journal of AHIMA website on November 1, 2016 and is republished here with permission. Attending the 2016 AHIMA Annual Convention and Exhibit in Baltimore, MD had its pros and cons. The pros: unbeatable networking opportunities and the chance to hear astronaut Captain Mark Kelly and former US…

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CDI is Expanding as Need for Quality Documentation Grows

Article by Tammy Combs. This article was originally published on the Journal of AHIMA website on June 23, 2016 and is republished here with permission. Clinical documentation improvement (CDI) programs are quickly emerging in various areas of the healthcare arena. We now see these programs specializing both prior to and beyond the acute hospital admission. Just as…

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Unfinished Business

By Susan Chapman for For The Record Findings from The Joint Commission show many surveyed hospitals house incomplete medical records. When so many aspects of health care revolve around quality documentation, it would be good to know that providers are accomplished medical record custodians. Depending on your perspective, the news on that front isn’t half…

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