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Winning the Coding Trifecta: CAC, CDI, and ICD-10. How CAC Can Strengthen Your CDI Program and Increase Collaboration with Coding and Quality Improvement

Author: Whittle, Kelly

Source: Journal of AHIMA

Publication Date: September 2016



It’s no surprise that the volume of clinical documentation has multiplied exponentially with the advent of electronic health records (EHRs). Templates, shortcuts, drop-down menus, and copy-and-paste functions make it easier than ever to document copious amounts of data with just a few cli....

Why You Should Care About Clinical Documentation

Author: Sims, Kimberly F

Source: CodeWrite

Publication Date: January 2016

Objective


The objective of this article is to look at how specific and detailed documentation written by the physician can assist with coding procedures with the root operation excision.



The introduction of ICD-10 has brought about an increased need to ensure th....

When Documentation Supports a Procedural Complication Diagnosis

Author: Reed, Andretta

Source: CodeWrite

Publication Date: April 2016



The challenges of reporting Present on Admission (POA) indicators on inpatient accounts continue after ICD-10 implementation. With diagnoses that link to Hospital Acquired Conditions (HACs), coding professionals must ensure the correct code and POA indicator are chosen. The reporting not o....

What's Up With Sepsis...Again

Author: Easterling, Sharon

Source: CodeWrite | AHIMA newsletter article

Publication Date: August 2016



BACKGROUND


Much discussion among medical, coding, and clinical documentation professionals has followed the recent release of the Sepsis-3 (Sep-3) definition, "Life-threatening organ dysfunction caused by a dysregulated host response to infection," published in JAMA: The Jour....

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