CDI Insights

Monthly CDI Discussion – Brain Compression

By Matt Hare / April 4, 2019

Topic: Brain Compression Scenario: 80 y/o m presents with c/o left sided weakness, limping, recent slurring of speech, and lethargy. Recent rollover MVC while out of the country – No CT/MRI head completed at that time. CT head reads – Large R SDH with approx. 1.3 cm midline shift and subfalcine herniation and impending transtentorial…

Medical Coding

Expanding Clinical Validation: What Is It, and Why Is It Important? 

By Tara Bell / November 1, 2018

In the CDI arena, there is an increasing focus on clinical validation – and for good reason. According to the Centers for Medicare and Medicaid Services’ (CMS) 2011 Recovery Audit Contractor (RAC) Statement of Work, “Clinical validation is a separate process [from DRG validation], which involves a clinical review of the case to see whether or not the…

ICD-11 Is on the Horizon. Here’s How US Healthcare Organizations Should Prepare

By Mary Stanfill / October 14, 2018

Just as many US healthcare organizations are hitting their stride in ICD-10 implementation, more changes are on the horizon. This past June, the World Health Organization (WHO) released the first complete draft of the next iteration in its International Statistical Classification of Diseases and Related Health Problems, ICD-11. This version is very different from the…

UASI in ACDIS: “Outpatient clinical validation queries offer advanced CDI opportunities” 

By Staff / October 10, 2018

UASI’s Tara Bell, MSN, RN, CCDS, CCM was recently interviewed for the ACDIS blog concerning the opportunities for CDI in the outpatient setting. Click here to read the full interview.  Bell is slated to present “Clinical Validation: Expanding Clinical Validation into Outpatient CDI” at the ACDIS Symposium: Outpatient CDI Conference in November.  A “Different Dialect:” Moving from Inpatient to Outpatient Coding  In…

UASI Solutions

Best Practices for Building a Remote CDI Model

By Staci Josten / June 19, 2018

10 Key considerations to evaluate remote CDI readiness “Will I ever have an opportunity to work from home?” It’s a question often asked by Clinical Documentation Specialists (CDS). As a CDI leader, you’ve likely heard it, most likely by some of your most experienced, productive employees and those most respected by physicians. Perhaps your initial…

UASI Solutions

Ten Steps to Create a Successful Outpatient CDI Program

By Staci Josten / June 6, 2018

Outpatient clinical documentation improvement (CDI) is a critical topic among those involved in mid-revenue cycle processes. It can sometimes be a challenge deciding where and how to get started. We’ve simplified the process by outlining our recommendations. Read ten key steps to successfully implement an outpatient CDI program for accurate capture of HCC’s (referred to as a Physician Practice CDI Program).

UASI Solutions

UASI in JAHIMA: “Improving Specificity in ICD-10 Diagnosis Coding”

By Jacquie Zegan / April 5, 2018

Unspecified diagnosis coding continues to be a problem in the US healthcare industry. For many organizations, overuse of nonspecific diagnosis codes has resulted in reimbursement delays and, in some cases, preventable claim denials.

UASI Solutions

UASI in JAHIMA: “Bridging the Gap Between Coding Guidelines and Sepsis Clinical Criteria”

By Natalie Sartori / February 5, 2018

In the January 2018 edition of the peer-reviewed Journal of the American Health Information Management Association (JAHIMA), UASI corporate trainer Natalie Satori, MEd, RHIA, published an article that seeks to clear up some of the confusion surrounding clinical criteria, as they pertain to coding guidelines and clinical validation specifically for sepsis.