Clinical Documentation

Coding for Gender-Affirming Health Care

By Susan Chapman, MA, MFA, PGYT for For The Record Gender identity is how individuals perceive themselves, be it different or the same as the sex they were assigned when they were born.1 Gender identity differs from gender expression in…

FY 2025 IPPS rates changed last minute due to court decision

From ACDIS CDI Strategies To comply with a summer court order, the fiscal year (FY) 2025 Hospital Inpatient Prospective Payment System (IPPS) was revised a day before its implementation on October 1 to reduce payments for low wage hospitals, JustCoding…

Dolbey at AHIMA24: Leading the Way in Health Information Management

As the healthcare industry adapts to rapid changes, health information management (HIM) professionals are at the forefront of improving patient care and operational efficiency. Dolbey is excited to announce that we will be attending AHIMA24, the American Health Information Management…

The unexpected consequences of hospital quality scores

By Alice Brewer for HealthcareDive One clinical affairs expert argues that it’s time to reexamine the federal Hospital-Acquired Condition Reduction Program. The latest list of hospitals facing federal penalties for poor quality has been released. Through hospital quality scores, the…

Clinical Documentation Integrity: Overcoming Query Challenges

By By Susan Chapman, MA, MFA, PGYT for For The Record A dozen best practices to help coding and CDI professionals create effective queries for accurate and comprehensive medical documentation. Coding and clinical documentation integrity (CDI) professionals use queries to…

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