It is no longer enough to confirm that a diagnosis is documented somewhere in the record. The documentation must also clearly demonstrate the clinical severity of the patient’s illness.
As artificial intelligence (AI) moves deeper into healthcare operations, from clinical documentation to coding and decision support, HIM leaders are being pulled into a more central, critical role.
Coding for alcohol- and drug-related disorders requires careful attention to both clinical terminology and the structure of the ICD-10-CM classification system.
As hospitals and health systems continue to acquire physician practices and bring providers under their umbrella, traditional coding models are starting to show their limits.
Most CDI programs focus their educational efforts on key documentation elements, but it's also important to instruct staff on terms to avoid in the medical record.
