ICD-9-CM Code 570 Acute and Subacute Necrosis of Liver

For those new to CDI, some conditions may cause difficulty in coding. Recently on the clinical documentation improvement forum CDItalk there was a question regarding the criteria needed for a diagnosis for acute and subacute necrosis of the liver. This particular member works with in an organization where they see many patients for liver procedures and was looking for some clarification on this particular issue. You can check out her full question, as well as the answer provided by DCBA.



Do you know the appropriate criteria for this condition? Have you ever been puzzled by a CDI question? Join CDItalk for free and bring your clinical documentation questions and insights to share with other professionals. You can also keep up with DCBA by signing up for the free publication CDI Monthly! What are you waiting for? Get connected with DCBA!

ICD-10 Implementation Deadline October 2015

The CMS recently announced that the official deadline for ICD-10 implementation is October 1, 2015. This means there is a serious need for healthcare organizations to be prepared for the changes ahead. The clinical documentation improvement publication CDI Monthly recently spotlighted the ICD-10 transition as well as the attributes of a successful CDI program. To learn more about clinical documentation improvement and how your organization can prepare for ICD-10, check out the resources offered by DCBA.




You can find valuable free information from CDI Monthly as well as the discussion forum CDItalk. Sign up free today and bring your clinical documentation improvement questions to the consultants at DCBA for valuable insights and tips for how to navigate even the toughest CDI problems. There is no better time to start thinking about ICD-10 preparation than right now. Get connected with DCBA and stay ahead of the curve!

CDI Monthly Newsletter

Looking for an easy way to stay connected to the world of CDI? Sign up for the clinical documentation improvement newsletter CDI Monthly from DCBA!

Each month, valuable information and insights are shared from the skilled clinical documentation improvement consultants at DCBA. Sign up for free with your email address and receive the new publication each month. While you're at it, don't forget to sign up for the leading clinical documentation improvement forum, CDItalk!

ICD-10 Preparation For Pediatrics

Healthcare providers need to be ready to make the transition to ICD-10 with the deadline set for 2015. In order to make the shift successfully, it is essential for physicians, nurses, coders, CDI professionals all must be on the same page to be able to best work together. The best option for providers is to seek out clinical documentation review and improvement.

Recent studies have shown that only about 37% of current physician documentation would meet the standards of ICD-10. For pediatric healthcare organizations who do not have a CDI program in place already, it is an essential step to gain results and streamline documentation efforts. Beyond getting ready for the transition to the new challenges that ICD-10 poses, CDI programs provide numerous other benefits which include: improving the quality of care and security of patients, more concise public reporting, reduction of denials and audits, less coding delays and physician queries, and an improved case mix index.

DCBA, a clinical documentation improvement solutions provider, has the experience and dedication to provide real results for your organization. With hundreds of success stories helping hospitals, clinics, and pediatric groups, DCBA brings in their experts to work with you. Onsite education is available to address the specific challenges and issues faced with ICD-10, and how they differ from ICD-9. In addition, electronic resources are available to staff to gain full benefit of the educational material. Pediatric healthcare providers all over the country have realized the benefits that ICD-10 training and CDI programs from DCBA have to offer, isn’t it time for you?

Coding Hypoxia Without Respiratory Failure

Looking for a list of conditions that would satisfy hypoxia or hypoxemia without being associated with respiratory failure? A member of CDItalk recently had the same question. You can find the question along with the answer here.


Challenges often present themselves when coding medical conditions. Fortunately, CDItalk is a free resource for professionals seeking help with tough coding issues. Join the forum free today and connect with skilled consultants who can provide accurate answers to your clinical documentation improvement questions. 

Acute Kidney Injury: Problems in Coding

Some medical conditions can present more challenges than others when it comes to coding. One topic that has come up many times on CDItalk is Acute Kidney Injury. Recently, a member of the forum posted a question regarding some complications that they were experiencing when coding AKI. Check out the post on CDItalk.

Has AKI presented difficulties for you before? Browse through the questions on CDItalk related to AKI by using the search function on the forum. You can find valuable free information about AKI with commentary by industry professionals. Join CDItalk to ask your CDI questions and gain answers to tough coding challenges. Join free today!

Question when Coding Accelerated Hypertension

CDItalk receives a range of questions regarding challenges faced in clinical documentation. Recently, a member came to the forum with a question about coding accelerated hypertension; check out the question here.

Have you ever had difficulty when coding accelerated hypertension? Do you ever wish you had a place to go to ask your CDI questions? Fortunately CDItalk is an excellent and free resource for those in the clinical documentation improvement industry. Skilled professionals share tips and insights and members can gain valuable information by taking part in real time discussion. Join CDItalk today!

ICD-10 Training For Hospitals

ICD-10 training is becoming more and more relevant for pediatric hospitals. This change will create some new documentation challenges for coders and clinical documentation specialists. With the new standards differing from ICD-9, an increased number of codes will allow for more specificity. This could mean that those who were proficient in ICD-9 could have difficulty working through the new guidelines. Healthcare providers who have not yet put in place a strategy to prepare for the changes must realize that the clock is ticking.

In addition to the new challenges with ICD-10, clinical documentation improvement programs can help children’s healthcare organizations increase case mix index, billing accuracy, and hospital profiles. Documentation directly supports coding which can affect hospital reimbursement and revenue. Starting a CDI program could be a key survival strategy for pediatric hospitals. Education is an essential first step towards finding solutions in pediatric clinical documentation improvement.

DCBA helps pediatric healthcare organizations with on site education as well as electronic resources to get ready for ICD-10. They can also analyze processes and put strategies into place that help create quality documentation results. Keeping staff on the same page is important so giving the proper tools to physicians, nurses, and billing and coding specialist provide a cohesive effort toward more accurate documentation. Children are not adults, and thats why DCBA has created CDI programs specifically for children’s healthcare.

Pediatric Clinical Documentation Improvement in ICD-10

Many children’s hospitals and pediatric groups are looking ahead and beginning preparations for the new coding set, ICD-10. The new system will surely present challenges for documentation specialists and coding professionals. With greater detail and an increased number of codes, ICD-10 will allow for greater specificity. This may present obstacles for those who are proficient in ICD-9. Preparation is key for the new coding set, and having a strategy in place to streamline documentation efforts will only benefit staff when the transition begins.

ICD-10 training is a critical step in preparation that can give employees the skills they need to become familiar with the changes ahead. In addition to training for the new coding set, seeking out solutions for documentation improvement prior to implementation of ICD-10 is a critical step towards a better transition. DCBA, a pediatric documentation improvement solutions provider, has helped hundreds of healthcare organizations across America to increase compliance, improve quality score, and improve CMI. With years of experience, and proven strategies, DCBA brings a results driven approach that has been proven time and time again.

What to Query from Ambulance Report

On CDItalk, a clinical documentation discussion forum, a member recently had a question regarding how they could query information from an ambulance report. They brought this question to the consultants at DCBA; you can read the question here and find out more about what to do in this situation.

Bring your CDI questions to CDItalk. You can join for free and gain insights from real industry professionals. Don't miss out on all of the valuable information available at this excellent source for clinical documentation improvement!

Hand Assisted Laparoscopic Partial Colectomies: How to Code

CDItalk, a leading clinical documentation improvement discussion forum, is constantly being updated with new questions and CDI updates. Here is a scenario that recently came up on the forum. Surgeons at a medical practice recently began performing hand assisted laparoscopic partial colectomy procedures. The coding staff felt unsure about the proper way to code these new procedures. The codes in question were 17.36 and 45.76. The member brought their question to the skilled consultants at CDItalk to find out the best way to handle this.

Have you ever had trouble with coding a new procedure? Bring your clinical documentation improvement questions to CDItalk. Becoming a member is free and the resources available are invaluable. Join CDItalk today!

How to Code Pulmonary Hypertension with Right Heart Failure

On the clinical documentation improvement forum CDItalk, a member recently had a question regarding pulmonary hypertension in a patient with right heart failure. There was some confusion as to how to properly handle the codes, and those in question were 416.8 and 428.0. Check out the forum to find out the way to approach this clinical documentation challenge.

Have you ever had a similar experience? Join CDItalk and share your CDI questions and insights. Membership is free so what are you waiting for! Join CDItalk and get connected.

How to Code Neutropenic Fever in AML: ICD-10

Medical conditions can present a challenge to properly code, even for those who are skilled and experienced. In a recent question posted to the clinical documentation improvement forum CDItalk, a member asked about how to handle a patient who was experiencing neutropenic fever with acute myeloid leukemia.

Check out the discussion on CDItalk and find the answers to this clinical documentation question, as well as others. Join the forum for free and stay connected!

Greater Specificity in Pediatric Clinical Documentation

When it comes to clinical documentation, it is important for pediatric healthcare organizations to have clear communication. Along with communication, specificity is key. Preventing things from getting lost in translation can mean increased quality scores. Patients, physicians, and coders all benefit from an increased level of detail. So how do pediatric hospitals gain greater detail and specificity in coding? By seeking out the consultation of skilled pediatric CDI professionals.

Implementing a clinical documentation improvement program in your hospital has numerous benefits. Case mix index can be increased, as well as compliance, and revenue. The scope of these benefits are not limited here, and hospitals will continue to benefit for years to come from  the education provided by CDI specialists. With more issues on the horizon, there is no better time than now to begin your program.

DCBA, a clinical documentation improvement company, helps children’s hospitals and other pediatric health care organizations to advance their current documentation, and help bring about the clearest communication between staff. With years of experience helping pediatric hospitals, as well as adult acute care hospitals, DCBA brings excellence in the field of clinical documentation improvement.

ICD-10 Training for Pediatric Hospitals

ICD-10 training is becoming more and more relevant for pediatric hospitals. This change will create some new documentation challenges for coders and clinical documentation specialists. With the new standards differing from ICD-9, an increased number of codes will allow for more specificity. This could mean that those who were proficient in ICD-9 could have difficulty working through the new guidelines. Healthcare providers who have not yet put in place a strategy to prepare for the changes must realize that the clock is ticking.

In addition to the new challenges with ICD-10, clinical documentation improvement programs can help children’s healthcare organizations increase case mix index, billing accuracy, and hospital profiles. Documentation directly supports coding which can affect hospital reimbursement and revenue. Starting a CDI program could be a key survival strategy for pediatric hospitals. Education is an essential first step towards finding solutions in pediatric clinical documentation improvement.

DCBA helps pediatric healthcare organizations with on site education as well as electronic resources to get ready for ICD-10. They can also analyze processes and put strategies into place that help create quality documentation results. Keeping staff on the same page is important so giving the proper tools to physicians, nurses, and billing and coding specialist provide a cohesive effort toward more accurate documentation. Children are not adults, and thats why DCBA has created CDI programs specifically for children’s healthcare.

Pediatric Clinical Documentation in ICD-10

Many who consult with physicians and healthcare organizations treat pediatric concepts the same as they would adult acute care. They feel that the same principles apply across the board. This could not be farther from the truth. Children are not adults. Their illnesses and conditions vary from those in the adult and geriatric age groups. Children’s cardiologists are not going spend much time becoming educated on ischemic heart disease. Pediatric healthcare organizations need solutions to issues that they face in their sector.

ICD-10 will mean greater specificity for documentation and coding staff. Those who are proficient in ICD-9 may have difficulties with ICD-10 without necessary preparation. For instance, diabetes as a condition has expanded to over 200 codes, a significant leap from the 60 something codes prior. But, because our practices have changed greatly since ICD-9 was implemented in the late 70’s, the need for a new system is upon us.

Greater attention to detail is key with coding. Communication is vital for success.With the experience of helping hundreds of organizations and a skilled consulting team of doctors, nurses, and coders, DCBA brings it’s experts in to address the issues that children’s hospitals deal with. By working directly with hospital staff and providing on site education as well as online resources DCBA delivers strategies that are specific to each organization. With the help of CDi Trax software, documentation specialists can streamline their processes and better manage their workflow. DCBA strives to provide solutions and results with the highest level of service in the industry.

Clinical Documentation Improvement Newsletter

Check out the CDI newsletter from DCBA to stay connected with news and updates in the world of clinical documentation improvement. Take a look at the the June 2014 edition here. Sign up free today and receive news and updates from one of the top consulting firms in the country!

Clinical Documentation Improvement Monthly

Are you looking for a way to stay in touch with the world of clinical documentation improvement? Look no further than CDI Monthly from DCBA!

CDI monthly keeps you up to date with industry news and keeps you connected with one of the country's top clinical documentation solutions provider. Sign up for CDI monthly free and while you're at it, join CDItalk, the leading discussion forum for CDI. Get connected!

ICD-10 To Bring More Codes, Detail

Most healthcare providers are bracing for ICD-10’s implementation. Many organizations have taken steps to prepare for the coming shift, but there are still groups who need assistance. Two keys for preparation are to gain ICD-10 training for employees and seeking out a clinical documentation improvement program to strengthen understanding and gain consistency.

ICD-10 will mean greater specificity for documentation and coding staff. Those who are proficient in ICD-9 may have difficulties with ICD-10 without necessary preparation. For instance, diabetes as a condition has expanded to over 200 codes, a significant leap from the 60 something codes prior. But, because our practices have changed greatly since ICD-9 was implemented in the late 70’s, the need for a new system is upon us (some would say overdue.)

The greater specificity of ICD-10 isn’t frightening, it is essential and will be much better for health care in the long run. DCBA, a clinical documentation improvement company, has been helping clients all over the country prepare for the coming changes that ICD-10 will bring. By working directly with staff with industry professionals, they provide comprehensive solutions to get pediatric hospitals prepared. Documentation improvement programs hold many advantages that can lead to increased compliance, productivity, and revenue.

CDI Question: Neutropenic Fever in AML

Do you have clinical documentation improvement questions? Some documentation and coding scenarios bring about challenges which are difficult to navigate. Fortunately, you can bring your CDI questions to CDItalk, the industry leading clinical documentation improvement forum.

Check out this recent question that was posted to the forum and don't forget to sign up!

Clinical Documentation Improvement Monthly News

Each month, DCBA releases a new edition on CDI Monthly with news and updates from the world of clinical documentation improvement. In the most recent edition, DCBA recaps the 2014 ACDIS conference and interviews pediatric lead consultant, Dr. Dan Catalano. There is also some great information about the ACDIS conference and CDI advice from Kelli Estes, RN, CCDS. If you haven't subscribed yet, be sure to sign up for CDI Monthly and stay in touch with up to date CDI news each month!

ICD-10 Advice: Take Advantage of the Delay

Some folks have determined that their already-started initiatives into ICD-10 can be placed on hold with the delay in start dates for the conversion of ICD-9 to ICD-10. Forward thinking facilities have determined that they can make positive moves which would have been tougher for them to complete with the original drop dead date of 1 October 2014. To these, I say “Congratulations on foresight.” To the others, I warn that much of your investment up until now will be thrown away and it’ll cost you SO much in the long run.

What are some of the benefits of continuing the course?

Well, the medical staffs of many hospitals, of many group practices are overwhelmed with conversions to electronic versions of health records, learning new daily routines that interfere with their practice, overwhelmed with learning about the Accountable Care Organizations and the various models of change in the system in their communities and their hospitals that a concerted effort to learn a new diagnostic language on top of that would be burdensome.

With the additional time available, one doesn’t have to burden the medical staff with Computer Based Learning modules, which are not designed for their particular need and take them away from patient care more than before, but can little by little insinuate terminology and specificity into your existing or new CDI programs. With 18 months’ time to get familiar with these requirements, they’ll be used to it all by the time it becomes mandatory. They’ll already be there.

Besides, there is no software package ready for the individual practitioner or even the hospital based practitioner that is clinically friendly, so with the lack of support for those who don’t have an EHR to the inadequate support for those who do, it’s a strain on the docs. The processes in the existing EHRs aren’t too physician friendly to begin with – yet.

And, regardless of how many courses a CDI specialist takes from Computer Based Learning modules, it’s not until the teams actually get to practice for months and months that they’ll ever get it – and you don’t want to turn CDI folks into on-the-fly book-dependent practitioners. Their productivity would reduce massively and there would be no measurable effects of their efforts as there has been with many of them until now. Getting them indoctrinated into the same specificity and terminology and working with them to use it over time, by 1 October 2015, they’ll already be there. And the expensive program won’t be necessary.

Now is the time to charge forward rather than turning back. To be able to get physicians familiar with terminology and specificity they will hear about the rest of many of their professional careers, the earlier without pressure, the better. To be able to get existing CDI members trained, specialty by specialty, disease by disease rather than by coding module by coding module will permit them to learn, assimilate, become familiar and work with this system painlessly with the medical staff and with live charts.

The modifications the docs will encounter over the next year and a half will be easy to swallow. With the conversion spread over a longer period of time, it will hardly be noticeable and will not be a distraction. And the sooner it gets started, the less difficult it will be in the long run, when it really counts for billing. And the new words are still billable! The worst thing with starting this all now is that you’ll have better information in the charts regarding the patients. And, in my mind, that’s “meaningful use.”

For those facilities that don’t have a CDI initiative, THIS is the time to get it going – to get the training over time – to get the support over time – to get the familiarity over time. And the fear goes away. For those that do have a CDI program, this is the time to get the team upgraded to the needs of the future and not dwell on the no longer valuable models of the past.

Yes, someone will come out with a physician-friendly software package. One that will work in the hospital, in the office and will really be able to communicate properly for the patient, which none of the programs currently do, no matter how many bells and whistles you hear about. And when that comes to pass and when we do graduate to 10th Grade, we’ll all be ready for college. Those that drop out of school will have to take additional night courses later and nobody will be happy

CDI Talk Monthly Newsletter

Each month, DCBA releases a free newsletter sharing news, updates, and insights from the world of clinical documentation improvement. This has proved to be a valuable resource for industry professionals looking to stay up to date with information. Join free today and share with your co workers!

Pediatric Clinical Documentation Improvement Program

Pediatric hospitals face unique challenges every day. One of the major areas where issues can arise is within the documentation of hospitals. Many factors can contribute to inaccuracies in coding and lost data. This can cause confusion and revenue loss when documentation issues go unresolved. Pediatric specialty service providers can experience a range of different scenarios in a fast paced environment. Pediatric specialty documentation and coding can be difficult due to the high level of complexity in the conditions, diagnoses, and treatments.

Human error is one of the largest causes of mistakes in documentation. Because there is so much information for any given patient in a clinical setting manually recorded data from multiple people can create room for error. It is easy for things to get lost in translation and minor differences in shorthand could mean major differences in procedure.

Due to the complexity of the conditions and body systems dealt with in pediatric specialty care, documentation can be challenging. Because multiple codable components can lie within a single condition, things can easily go overlooked. Aside from omissions, failure to properly note findings can cause issues as well.

DCBA, a leader in pediatric documentation improvement, has developed strategies that specifically address the challenges faced by today’s pediatric healthcare specialists. By educating physicians, coders, nurses, and documentation specialists, DCBA creates a cohesive network of understanding in the ever changing field of pediatric medicine. Through their efforts helping various clients across the country, DCBA has created a results driven approach to tackling tough issues in pediatric documentation. Ready for improvement? Check out DCBA.

Clinical Documentation Improvement News

Looking for the latest clinical documentation improvement news? The best place to go for news and updates in the world of clinical documentation improvement is CDItalk and CDI monthly!

CDItalk is the leading discussion forum for clinical documentation improvement. At CDItalk you can interact with other CDI professionals, ask CDI questions, and share your own CDI insights. Sign up free here!

CDI monthly is another great resource for Clinical Documentation Improvement news. Each month, members receive the monthly newsletter via email. It's a great way to stay connected with what is going on in the industry.

Both of these resources are free and invaluable to those looking to stay in touch with the ever changing field of clinical documentation improvement.  

Clinical Documentation Improvement Monthly

Looking for the best way to stay current with the clinical documentation improvement industry? Check out CDI monthly!

This free service provides news and updates from the world of clinical documentation improvement each month right in your e-mailbox. CDI monthly goes right along with CDItalk, the leading clinical documentation improvement forum.

CDItalk provides helpful information and platform to discuss challenges in coding, news, and a place to share helpful insights with peers. Join CDItalk and CDI monthly free today and get connected!

ICD-10 : When to code?

With the new codes and changes of ICD-10 it can be difficult for those proficient in ICD-9 to determine when to code certain conditions. With time and practice, these new codes and changes will soon become second nature but until then there is one place you can go to ask your coding questions.


CDItalk is the country's leading clinical documentation improvement forum. With updates on the industry and up to date discussions on clinical documentation improvement, CDItalk is a great resource. Check out this recent discussion about when to code Ruptured Chorde Tendinae. Also be sure to sign up for free monthly CDI updates here!

ICD-10 Advice From Kelli Estes

CDI Review Notes – How much is too much?

Compiling a “CDI version” of the documented H & P is too much!

Inevitably, CDSs need to make notes to prompt their thoughts about the cases they review, but there is much better use of time and productivity by honing in on what lacks in documentation rather than copying what is already well stated.

In defense of a CDS “newbie”, writing down more clinical content in the review notes is understandable and certainly expected while training. However, as the CDS matures, irrelevant content will become much clearer thus resulting in less daily review notes.

The CDS must gain perspective regarding the intent of review notes. The logic behind review notes is to assist any CDS with being more efficient in their work not a burdensome process eating away excessive amounts of time. In reality, CDI review notes are intended to serve as a quick reference to the potential need for pursuing improved documentation via physician clarifications.

It is important to note that the vast majority of CDSs entering the marketplace are nurses. Nurses are trained to give and receive shift reports encompassing a thorough overview of the patient’s active medical problems as well as past medical history, treatments, labs, x-rays, diet, activity, etc. This is part of a process embedded into the standard training for nurses. As a nurse, it is difficult to embrace different methods of note taking as it relates to the world of CDI. Like any learned process, it is difficult to make changes.

Additionally, nurses are not coders. However, they need a “working knowledge” of coding to do their job well. Because of this, they sometimes feel the need to write more than what’s necessary. It helps to have a strong “working knowledge” of coding to understand how certain type notes will help compliment their work when identifying the need to obtain more specific physician documentation.

But, in the end, it would be most helpful to just keep it simple and review more cases!
Kelli Estes, RN, CCDS

http://cditips.com/excessive-note-taking-less-reviews-decreased-productivity/

ICD-10 Implementation Pushed Back

The HHS has officially pushed back the ICD-10 implementation deadline because they felt like it would maximize benefits to providers and minimize costs of delay. After weighing both the risks and consequences, the HHS felt that the delay provided the most regulatory balance. Even though the deadline has moved back, there is a great sense of urgency to prepare for the coming changes. Officials have stressed that hospitals need to begin making strides towards the new system.

Children’s hospitals face challenges that are unique to the field of pediatrics. With the implementation of ICD-10, there will be a new set of difficulties for coders and billing staff. An increased number of codes can mean greater specificity and those proficient in ICD-9 could have trouble adapting to the changes. Many children’s hospitals are seeking out the help of experienced consultants to assess their current state and prepare for the new system. Officials recommend not waiting, but instead, beginning a PDI program prior to ICD-10 implementation. This, in addition to training specifically for the new system, gives children’s hospitals the the greatest chances for a smooth transition.

DCBA provides on site education to prepare staff for ICD-10. They have also created CDI programs tailored to the unique field of pediatric medicine. DCBA brings years of experience from doctors, nurses, coders, and documentation specialists to consult with children’s hospitals and implement proven strategies for success. There has never been a better time to begin a PDI program than now. With comprehensive software and a detail oriented approach, DCBA brings real results to pediatric healthcare organizations.

Pediatric ICD-10 Training

Healthcare providers need to be ready to make the transition to ICD-10. In order to make the shift successfully, it is essential for physicians, nurses, coders, CDI professionals all must be on the same page to be able to best work together. The best option for providers is to seek out clinical documentation review and improvement.

Recent studies have shown that only about 37% of current physician documentation would meet the standards of ICD-10. For pediatric healthcare organizations who do not have a CDI program in place already, it is an essential step to gain results and streamline documentation efforts. Beyond getting ready for the transition to the new challenges that ICD-10 poses, CDI programs provide numerous other benefits which include: improving the quality of care and security of patients, more concise public reporting, reduction of denials and audits, less coding delays and physician queries, and an improved case mix index.

DCBA, a clinical documentation improvement solutions provider, has the experience and dedication to provide real results for your organization. With hundreds of success stories helping hospitals, clinics, and pediatric groups, DCBA brings in their experts to work with you. Onsite education is available to address the specific challenges and issues faced with ICD-10, and how they differ from ICD-9. In addition, electronic resources are available to staff to gain full benefit of the educational material. Pediatric healthcare providers all over the country have realized the benefits that ICD-10 training and CDI programs from DCBA have to offer, isn’t it time for you?

ICD-10 Training Programs

ICD-10 training is becoming more and more relevant for pediatric hospitals. This change will create some new documentation challenges for coders and clinical documentation specialists. With the new standards differing from ICD-9, an increased number of codes will allow for more specificity. This could mean that those who were proficient in ICD-9 could have difficulty working through the new guidelines. Healthcare providers who have not yet put in place a strategy to prepare for the changes must realize that the clock is ticking.

In addition to the new challenges with ICD-10, clinical documentation improvement programs can help children’s healthcare organizations increase case mix index, billing accuracy, and hospital profiles. Documentation directly supports coding which can affect hospital reimbursement and revenue. Starting a CDI program could be a key survival strategy for pediatric hospitals. Education is an essential first step towards finding solutions in pediatric clinical documentation improvement.

DCBA helps pediatric healthcare organizations with on site education as well as electronic resources to get ready for ICD-10. They can also analyze processes and put strategies into place that help create quality documentation results. Keeping staff on the same page is important so giving the proper tools to physicians, nurses, and billing and coding specialist provide a cohesive effort toward more accurate documentation. Children are not adults, and thats why DCBA has created CDI programs specifically for children’s healthcare.

Getting Ready For ICD-10

Most healthcare providers are bracing for ICD-10’s implementation. Many organizations have taken steps to prepare for the coming shift, but there are still groups who need assistance. Two keys for preparation are to gain ICD-10 training for employees and seeking out a clinical documentation improvement program to strengthen understanding and gain consistency.

ICD-10 will mean greater specificity for documentation and coding staff. Those who are proficient in ICD-9 may have difficulties with ICD-10 without necessary preparation. For instance, diabetes as a condition has expanded to over 200 codes, a significant leap from the 60 something codes prior. But, because our practices have changed greatly since ICD-9 was implemented in the late 70’s, the need for a new system is upon us (some would say overdue.)

The greater specificity of ICD-10 isn’t frightening, it is essential and will be much better for health care in the long run. DCBA, a clinical documentation improvement company, has been helping clients all over the country prepare for the coming changes that ICD-10 will bring. By working directly with staff with industry professionals, they provide comprehensive solutions to get pediatric hospitals prepared. Documentation improvement programs hold many advantages that can lead to increased compliance, productivity, and revenue.

Pediatric Documentation Challenges

The field of pediatric healthcare is constantly evolving, bringing with it new ideas, practices, and procedures. Though the future constantly brings new things, accurate clinical documentation will always be a necessity. In pediatric documentation, there is a vast amount of data generated every day. With multiple data streams, it is not uncommon for information to get lost in the pipeline or misinterpreted. Communication is key for accurate data. When physicians, nurses, CDI specialists, and coders are on the same page, true improvements in documentation can be made.

DCBA provides consultation and education for pediatric hospitals seeking to enhance their current clinical documentation practices. With ICD-10 implementation approaching, there has never been a better time to begin streamlining the documentation process. Comprehensive software, results based strategies, and a detail oriented approach make DCBA a leader in the field of pediatric clinical documentation improvement. They have helped hospitals across the country to achieve their goals and enhance their profiles, increase CMI, and improve quality scores.

Benefits Of PDI

One of the most important factors in developing a more effective documentation program is that both the physicians and administrative staff see the value of improving the process. It is essential for hospital administration and physicians to work together on common goals to have a successful program. PDI programs can be tailored to operate with an organization’s existing program, implementing strategies where needed to help increase both productivity and profitability.

Children’s conditions differ from those of adults. Because of this, accurate documentation of pediatric conditions is important for proper coding. By seeking solutions to create more efficient documentation, pediatric healthcare organizations can gain increased compliance, improve their CMI, and enhance their profile. Pediatric clinical documentation improvement programs can help create more consistency across board. It is beneficial for children’s hospitals to seek out the experience of a PDI company who understands their needs.

DCBA, a CDI solutions provider, knows what it takes to foster a successful documentation strategy. By consulting with professionals across the country, they can stay up to date with current trends, issues, and news in the industry. DCBA can provide on site education as well as online resources for staff. With years of experience creating solutions for pediatric healthcare organizations, they bring the combined knowledge of industry professionals to find the right strategies for any organization.  

Pediatric Clinical Documentation For Children's Hospitals

Many who consult with physicians and healthcare organizations treat pediatric concepts the same as they would adult acute care. They feel that the same principles apply across the board. This could not be farther from the truth. Children are not adults. Their illnesses and conditions vary from those in the adult and geriatric age groups. Children’s cardiologists are not going spend much time becoming educated on ischemic heart disease. Pediatric healthcare organizations need solutions to issues that they face in their sector.

Documentation plays a critical role in pediatric hospitals. Streamlining documentation efforts can create numerous benefits for patients, physicians, administration, as well as billing and coding staff. PDI programs can lead to an increase in patient quality scores. Greater documentation can lead to physicians and coding staff capturing more information than they would have before. Administration can see increased revenue, easier filtering and resolution of claims, and improved profiles. Pediatric clinical documentation programs can lead to increased profitability and compliance for organizations who take steps towards greater accuracy and proficiency in documentation and coding.

DCBA has worked with hundreds of hospitals and healthcare organizations to implement successful clinical documentation improvement programs. Their clients include some of the largest pediatric care providers in the country. With years of experience in medicine and clinical documentation consulting, DCBA brings the experience of leading industry professionals to tackle the specific needs that pediatric healthcare organizations face. They work with physicians, nurses, mid level providers, and other medical professionals to implement a cohesive hospital wide pediatric clinical documentation improvement program.