Documentation improvement

CDI staff must be able familiarize themselves with missing clinical indicators that commonly lead to denials.

Review education strategies for CDI professionals to improve documentation, reduce denials, and boost accuracy in medical records.

When an office/outpatient visit is coded based on time, think beyond face-to-face time to get full credit. This article reviews time-based coding, how to count time, which activities count toward time, and which ones don’t.

Analyze how using more technology to carry out various clinical documentation integrity (CDI) functions could impact your organization.

Review recommendations and tips for attending physicians regarding the incorporation of CDI principles into medical student documentation education.

Enhance your understanding of coding conventions, language, and appendices to better support CDI record review.

Review medical necessity documentation tips and query strategies to ensure proper reimbursement.

Learn about the benefits of creating clinical guidelines at your organization. 

It can be especially challenging to thoroughly document rendered services in the emergency department due to the unique needs of the setting. Hamilton Lempert, MD, CEDC, reviews several areas of critical care coding that may trip up clinicians and coders.  

It’s easy to get overwhelmed or not know where to begin when embarking on an expansion project. Review these considerations before you leap into outpatient CDI.