As CDI programs move deeper into the post-implementation world, staff are identifying those changes that are having the greatest effect on DRG assignments, and those they are struggling with. Here are a few documentation issues that stand out.Read More »
ICD-10-CM/PCS brought some new challenges in coding neonatal records. The term “newborn” has replaced the term “fetus or newborn” in the ICD- 10-CM code set. This change ensures that these codes will only be used on the neonate’s...Read More »
The AHA’s Coding Clinic for ICD- 10-CM/PCS, Third Quarter 2015, opens with a discussion of the differences between excisional and non-excisional debridement—diagnoses with a long history of causing coding and clinical documentation...Read More »
In the past 15 years at Sarasota Memorial Health Care System in Florida, there were two unsuccessful attempts to implement a CDI program. So when Joannie Crotts, RN, BSN, CPC, took on the project back in 2011, shortly after accepting her first CDI position, she had her hands...Read More »
The CDI Journal offers CE credits towards the ACDIS CCDS certification. To obtain your CCDS continuing education credits, you must successfully complete the online continuing education quiz. Please note: The expiration date for this activity is January 1, 2017. You must complete your online quiz...Read More »
We believe that the CDI profession may be well poised as the architects of the sturdy infrastructure needed in this new landscape. After all, the profession was built on change.Read More »
Reconciliation is the process of reviewing medical record documentation and comparing this information to the coding summary: principal diagnosis, secondary diagnoses, present on admission indicators, procedure(s), and discharge disposition.Read More »
