Category Archives: Clinical Documentation Improvement

Concurrent Documentation Review; CDI; concurrent chart review; complications and comorbidities; MCCs; Co-morbidities; Severity of Illness; SOI; Risk of Mortality; ROM; documentation at the point of care; MS-DRGs; Medicare Severity DRGs; APR-DRGs; casemix; case mix index; CMI; risk adjustment; chart completion

HIMagine That! Collaborating on ICD-10 Documentation

Donna and Sue are joined this month by fellow 3M HIS blogger Jill Devrick.

Donna: Hi Sue. How was the AHIMA-AHDI summit? Didn’t you give a presentation?

Sue: The summit was really good, and yes, Jill Devrick and I gave a presentation on how CDI professionals and Healthcare Documentation Specialists can work together to improve the content of the medical record in light of the transition to ICD-10.

Donna: So tell me more…

Sue: You know what, let’s get Jill on the line and we can both tell you about it… Continue reading

HCCs: Don’t Underestimate Their Importance

So there are PPCs and HACs, PPRs and PPAs, PSIs and VBP just to name a few. But please don’t forget or underestimate the importance of HCCs. Why should you care about HCCs? HCCs are Hierarchical Condition Categories (there’s a mouthful). In simpler terms, HCCs are diagnoses/conditions that are present in the patient that complicate their care and management and require more resources to treat. Sounds easy enough right? Continue reading

HIMagine That! Queries for ICD-10

Donna: You know Sue, I think that people are really stepping up their ICD-10 game as we enter the home stretch.

Sue: The way I look at it, they’ve been stepping up their game for the last five years!

Donna: So true. Still, I’ve received a lot of emails lately from coding and CDI professional requesting assistance with ICD-10 queries that they can use to ensure they have ICD-10 ready documentation.

Sue: So what kinds of queries are they asking about? Continue reading

“My Patients Are Sicker”…Prove it!

When thinking of quality outcomes improvement, much focus is on the particular quality concern (such as a readmission, accidental laceration, etc.) and reducing the incidence through better practice, improved documentation or coding. But not enough attention is focused on risk-adjustment for the various quality indicators. And sadly, this is the easiest part to fix! Continue reading

Documentation Quality: Time to Line up the Ducks

The Joint Commission’s (TJC) current “Quick Safety” article, intended to advise healthcare organizations about safety and quality issues, is about the potential risks when technology and human workflow practices do not ensure patient documentation is accurate, complete, and understandable. Although the title of the article is, “Transcription translates to patient risk,” the gist of the article is that documentation being captured via dictation and transcription, speech recognition technology, direct entry into templates, straight typing by providers, or any other method, needs to be reviewed with utmost care to protect patients from injury and death. Continue reading

Present and Accounted For…Potentially Preventable Complications

We all know the phrase “First do no harm,” a philosophy that is a driving force in health care. In other words, if we do not do anything to improve the health of our patients during their stay, at least let’s not allow anything bad to happen to them on our watch. Continue reading

Where Would We Be Without Clinical Coders?

I’m sitting on a plane today, traveling through the air as a result of some very bright people that enabled this mode of transportation. I’m doing so safely, thanks to strict airport security practices. Many years ago, when more stringent airport security screening was established, I would listen to fellow travelers complain about the invasion of privacy, the maybe not-so-random searches and the added expense tacked on to everything. And the lines in security, oh the lines! However, as a frequent traveler I’m forever thankful for the process we flyers have to go through to ensure the safest passage possible. Continue reading

Better Living—and Documentation—Through Computer Assistance

Have you ever driven a car without power-steering? It’s quite a workout. We used to all drive without power-steering and for “entertainment” you had to spend ten minutes twisting a small dial back-and-forth trying to get a radio station to come in clearly, only to drive under a bridge and completely lose it. Now we’re on the verge of self-driving cars and I can stream an entire album saved in the cloud into my car just about anywhere and anytime I want. No more fine-tuning that pesky radio dial. Continue reading

My Wish List for HIMSS15: Bring Documentation into the Health IT Conversation

For the past two years, I have been fortunate to attend the HIMSS Annual Conference & Exhibition in both New Orleans and Orlando. HIMSS puts on a massive event for about 38,000 people, so it’s definitely a great place to learn and network around the newest technologies, trends, and solutions in healthcare information technology. HIMSS15 kicks off in Chicago on April 12, and although I am unable to attend this year, I’ve been thinking about the conversations and ideas I hope will be generated by the organizers, presenters and attendees. Continue reading

Observation Services: Documenting Medical Necessity (Part One)

I shudder to think about the compliance quicksand surrounding observation services. Regardless, I’m going to attempt to explain how to document medical necessity for observation services (OBS). Fortunately – or unfortunately – depending on how you look at it, documentation requirements for medical necessity for OBS is not the same for all payers. Continue reading