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Insights & Education

Monthly CDI Scenario Discussion – August 2019

By Matt Hare / August 1, 2019

Topic: Cardiac Arrest – the Underlying Condition Scenario: 19 y/o female brought to ED by ambulance accompanied by boyfriend The patient is found on presentation to the ED to be nonverbal, does not open eyes and has no motor responses Boyfriend reports to ED physician that patient ingested a large amount of heroin and was… Read More »Monthly CDI Scenario Discussion – August 2019

Monthly CDI Discussion – Complex Pneumonia

By Matt Hare / July 2, 2019

Topic: Complex Pneumonia Scenario: 82 yr. old female admitted from her skilled nursing facility with complaints of chest pain, SOB and cough with yellow mucus. Hx of COPD, on continuous O2 at 2L with recent hospital discharge for exacerbation, CVA with dysphagia. Assessment, patient noted with wheezing, rhonchi with mild dyspnea. VS: temp 99.2, HR… Read More »Monthly CDI Discussion – Complex Pneumonia

Monthly CDI Discussion – Rhabdomyolysis

By Matt Hare / June 6, 2019

Topic: Traumatic Rhabdomyolysis with Acute Kidney Injury due to Acute Tubular Necrosis Scenario: 50 year old female admitted after a motor vehicle accident where she was the restrained driver Patient with abdominal pain, nausea, tachycardia, muscle pain Patient sustained a fractured fibula/tibia of right leg Fractured ulna left arm Multiple contusions and abrasions Creatinine on… Read More »Monthly CDI Discussion – Rhabdomyolysis

Monthly CDI Discussion – Non-infectious SIRS with Organ Dysfunction

By Matt Hare / May 2, 2019

Topic: Non-infectious SIRS with organ dysfunction Scenario: 65 year old male admitted with history of alcohol abuse and HTN Patient presents with abdominal pain and vomiting for 4 days Vital signs in ED: 160/90, HR 120, RR 24, T101.7F Labs: WBC 18.0, Lactic Acid 2.6 on admit, repeat in 24 hrs. 2.0, Blood Glucose 250… Read More »Monthly CDI Discussion – Non-infectious SIRS with Organ Dysfunction

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… Read More »Monthly CDI Discussion – Brain Compression

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… Read More »Expanding Clinical Validation: What Is It, and Why Is It Important? 

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

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… Read More »UASI in ACDIS: “Outpatient clinical validation queries offer advanced CDI opportunities” 

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… Read More »Best Practices for Building a Remote CDI Model

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).