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Reinventing CDI: Organizations Relaunching And Reworking Data Integrity Efforts, And Coding Roles, With Clinical Documentation Improvement Programs

Author: Butler, Mary

Source: Journal of AHIMA

Publication Date: July 2014



It’s a particularly busy night in the local hospital’s emergency department, which is running—as usual—slightly short-staffed. The on-call attending physician goes from room to room treating and diagnosing patients with typical emergency department maladies: influenza, fractured ankle, in....

CDI's Promise and Possibilities

Author: Gordon, Lynne Thomas

Source: Journal of AHIMA

Publication Date: July 2014




“The first job of a leader—at work or at home—is to inspire trust. It’s to bring out the best in people by entrusting them with meaningful stewardships, and to create an environment in which high-trust interaction inspires creativity and possibility.”

Improve Data and Outcomes with CDI

Author: Kennedy, Angela

Source: Journal of AHIMA

Publication Date: July 2014



ICD-10-CM/PCS will require significantly more clinical detail than ICD-9-CM, making clinical documentation improvement (CDI) efforts paramount for healthcare providers across the continuum of care. While CDI programs aim to substantiate claims and improve revenue streams, CDI itself shoul....

Use Data Mining Findings as a Tool to Support CDI Education

Author: Easterling, Sharon; Endicott, Melanie; Lojewski, Tedi; Maccariella-Hafey, Patricia C; Martin, Ginny

Source: Journal of AHIMA - Coding Notes | Journal of AHIMA

Publication Date: July 2014



Clinical validation involves the clinical review of a case to determine whether or not the patient truly possesses the conditions documented in the health record. Productivity and coding quality often suffer when the health record lacks accurate documentation to support the claim, and cur....

Bird’s Eye View of ICD-10 Documentation Gaps: Vendor analysis offers big picture look at nationwide documentation holes—and how to fill them

Author: Hinkle-Azzara, Barbara; Carr, Kimberly J

Source: Journal of AHIMA

Publication Date: June 2014



Increased clinical specificity is one of the greatest advantages of moving to ICD-10-CM/PCS. With specificity comes the ability to perform granular research that can help uncover significant trends and statistics to identify causes of diseases, links between diseases, and more. While heal....

Overcoming the Risks of Copy and Paste in EHRs

Author: Haugen, Heather

Source: Journal of AHIMA

Publication Date: June 2014



With warm weather comes allergy season and possibly hundreds of patients visiting a physician who have similar symptoms, diagnoses, and treatment recommendations. Challenged by the documentation processes in the electronic health record (EHR) and starved for time, the physician may resort....

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