Fusion CDI

Guest Blog: Clinical Validation

By Howard Rodenberg, MD, MPH, CCDS for ACDIS CDI Blog I think we’re all familiar with the Law of Unintended Consequences. That’s the concept that something begun with the best of intentions can wind up going horribly awry. Examples include “New Coke” and anything ending in the word “Kardashian.” (Although I’m not sure anything the…

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8 most common medical coding errors

By Morgan Haefner for Becker’s Hospital Review In June, federal officials charged 601 defendants in alleged schemes involving about $2 billion in costs to Medicare and Medicaid, the biggest healthcare fraud enforcement action in U.S. Justice Department history. Government and private health insurer audits have recently revealed several fraudulent or abusive medical billing practices, Kevin B. O’Reilly, editor…

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ICD-10-CM is Lacking Detail for Sexual Harassment

By Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer for ICD10 Monitor Clinical documentation will need to reflect these situations in order to be accurately coded. When beginning research for this article, I opened my 2018 ICD-10-CM book to the External Cause Index section, specifically for the word “harassment,” but it was missing. The…

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Auditing Issues Uncovered in Physician Documentation: Part IV

By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor Editor’s Note: This is the final installment in a four-part series that examines physician documentation issues as seen by an auditor. Click here to read part one: Auditing Issues Uncovered in Physician Documentation: Part I Click here to read…

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How to Improve the Query Process

By Marisa MacClary for For the Record The only way hospital clinical documentation improvement (CDI) and coding staff may compliantly clarify physician documentation for the purpose of accurate coding is to query the physician. The physician query process is essential to ensure accurate quality scores and proper reimbursement. However, most CDI specialists, coders, and physicians…

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Coding-Clinical Disconnect Reducing Apparent Child Abuse Incidence? Not on My Watch

By Erica E. Remer, MD, FACEP, CCDS for ICD10 Monitor Some providers hesitate to use the word “abuse” preferring, instead, to use non-accidental trauma (NAT). Despite what revenue cycle may believe, clinical documentation is not solely for billing. One of the biggest problems with imprecise, nonspecific diagnoses which lead to unspecified codes or, even worse,…

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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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