Clinical Documentation

Proper Documentation is Critical to Our Modern Healthcare System

Article by Allen Frady, RN, BSN, CCS, CCDS, CRC. This article was originally published on the Journal of AHIMA on March 29, 2018 and is republished here with permission. Is documentation improvement and proper use of ICD-10-CM critical to the nation’s healthcare debate? I say definitively yes, in every way. The bulk of the information coming from…

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EHR usability issues may contribute to patient harm, JAMA study shows

By Jeff Lagasse for Healthcare Finance  The usability of electronic health records may be associated with some safety events in which patients were possibly harmed, according to a new study published in the Journal of the American Medical Association. And while the authors did not make any specific financial revelations, clinical quality has increasingly been tied…

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Can Texting Get a Healthcare Provider in Trouble?

Article by Ron Hedges. This article was originally published on the Journal of AHIMA  on March 27, 2018 and is republished here with permission. Can texting get a healthcare provider in trouble? The answer to that question, like many other legal ones, is “it depends.” A recent decision, Latner v. Mt. Sinai Health System, Inc., No. 17-99-cv (2d Cir.…

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Why CDI Often Times Goes off the Rails

By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM for ICD10 Monitor  Moving beyond CDI to optimize reimbursement requires returning to an optimal and sustainable level of achievable excellence. A well-guided, thought-out, directed mission is paramount to driving and ensuring success in any professional role – and this particularly holds true…

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Improving Risk Adjustment through Inpatient HCC Capture

By Michelle M. Wieczorek RN RHIT CPHQ for ICD10 Monitor In this article, the author examines the implications for the capture of Hierarchical Condition Codes (HCCs) in the inpatient setting. By now, most clinical documentation improvement (CDI) programs have an appreciation for the use of cases reflecting how Hierarchical Condition Codes (HCCs) impact upon quality…

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We Won’t Get Value-Based Health Care Until We Agree on What “Value” Means

By Robert C. Pendleton for Harvard Business Review Some health care leaders view with trepidation the new, disruptive health care alliance formed by Amazon, Berkshire Hathaway, and JPMorgan Chase. But I’m excited because disruption is all about delivering a new level of value for consumers. If this trio can disrupt the United States’ health care…

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