Monthly CDI Discussion – Rhabdomyolysis
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…
Monthly CDI Discussion – Non-infectious SIRS with Organ Dysfunction
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…
Monthly CDI Discussion – Brain Compression
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…
Expanding Clinical Validation: What Is It, and Why Is It Important?
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
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”
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…
Best Practices for Building a Remote CDI Model
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…
Ten Steps to Create a Successful Outpatient CDI Program
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 in JAHIMA: “Improving Specificity in ICD-10 Diagnosis Coding”
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 in JAHIMA: “Bridging the Gap Between Coding Guidelines and Sepsis Clinical Criteria”
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.