Clinical Documentation Issues: New Encounters

As we all know, the world of medicine is constantly changing. As such, doctors, nurses, and documentation specialists are challenged with a variety of different situations and conditions on a daily basis. For clinical documentation specialists, situations can arise which lead to uncertainty on how to properly go about coding in these situations.

Fortunately, there is a place where you can go to ask questions and find out answers to tough CDI problems. CDItalk is the #1 clinical documentation improvement discussion forum in the nation with professionals sharing their experiences and insights daily. Check out this recent post from a member seeking how to properly handle a situation that she had never seen before.

Do you ever have issues determining how to properly handle a clinical documentation problem? Join CDItalk for free and ask your questions, share insights, and stay in touch with the industry.

ICD-10 Clinical Documentation Questions

With the official transition to ICD-10 just around the corner, many people have clinical documentation questions that would like to have answered. Some hospitals may have already undergone the shift, leaving CDS and CDI professionals with some difficult situations to navigate in the early stages. Fortunately, there is a place where those who need help with clinical documentation questions can go.

The discussion forum CDItalk is a great resource where those in the industry can go to ask tough documentation questions and get answers from experienced clinical documentation improvement experts. Take a look at a recent question, along with a great response from Dr. Robert Gold. If you have CDI questions or want to discuss issues with others in the industry, join CDItalk!

ICD-10 Transplant Complications

Some hospitals and healthcare organizations find themselves in a situation where many patients have similar conditions. Recently, on the clinical documentation improvement forum CDItalk, a CDS had questions regarding complications with transplants as there were many patients with these issues in their facility. Have you experienced difficulty when coding transplant complications in ICD-10? Join industry professionals from across the country on the leading CDI discussion forum today!

Top ICD-10 Documentation Problems

October is fast approaching and before long ICD-10 will be in full swing across the medical field in the United States. Greater specificity will be attained in ICD-10 and there will also be an increase in the amount of codes to decipher.

Some conditions are more complex than others, requiring certain protocols and methodology to appropriately classify the information. AHIMA listed some of the top problem areas for ICD-10, which were recently discussed on the clinical documentation improvement forum CDItalk. You can read more about these ICD-10 clinical documentation problems and join the discussion on the largest industry resource for real time CDI information.

ICD-10 Clinical Documentation Improvement

CDI, as it is typically used in hospitals, utilizes consultants who assess clinical documents and provide responses to physicians, says Dr. Robert Gold, CEO of DCBA. The responses given are intended to provide solutions to issues with documentation including questions about the coding used, quality, and management of the overall care of patients. As Dr. Gold Says, “Paint the picture of the patient properly with words, so the coder can paint the same picture with codes.”

Healthcare organizations can realize positive changes in accuracy and compliance. Take a look at what this CDI Liaison Nurse had to say about working with DCBA’s team:

I am still amazed everyday at the intensity and level of cooperation with documentation from the majority of our physicians. And I don’t take credit for it. It is an expectation of the leadership here, the staff follow through willingly, and the rest just happens. The physicians are pretty accessible on the floors so we are able to make frequent contact with them and educate as needed. We even had a metabolic doc come up to us and ask how to document an unusual condition that was present on admission. Even the pediatric surgeons answer our queries. And we are presenting to the new docs coming on board at the end of the month. So life here is good.

Coding Cardiopulinary Arrest in ICD-10

Transition to ICD-10 means greater specificity and more codes than ICD-9. The CMS deadline for transition is October, 2014 but some are already experiencing challenges in shifting to the new system.

In a recent discussion on the CDI discussion forum CDItalk, a question came up about coding procedures for cardiopulminary arrest. DCBA's Dr. Robert Gold shared some valuable information on the topic that was beneficial to the understanding of this condition.

You can keep up to date with industry news and ask your CDI questions on CDItalk- simply join the forum for free and get connected!

Coding Acute Ischemic Bowel ICD-10

Acute ischemic bowel affects the large intestine causing inflammation. Most often, it occurs in individuals over the age of 60, however it can occur at any age. With the transition to ICD-10, coding procedures may cause issues for some. Recently, the clinical documentation improvement forum, CDItalk had an inquiry about acute ischemic bowel. You can read the thread here. Join CDItalk to ask your CDI questions or to share your experiences.

Clinical Documentation Improvement Discussion

The world of clinical documentation improvement is constantly evolving and expanding along with the ever changing medical field. There are few places, however, to talk with others in the industry about the day to day battles that are faced each day. Fortunately, there is one resource that is both insightful and current-CDItalk.

CDItalk is the online clinical documentation resource for professionals. Membership is free and users have full access to all resources of the site. You can ask questions regarding coding practices or share your insights with others. What are you waiting for? Join today!

Coding Acute Respiratory Failure ICD-10

Acute respiratory failure is a condition in which fluid fills the air sacs of the lungs. Due to the nature of the condition, it can present some challenges to code appropriately in ICD-10. Join the latest discussion on acute respiratory failure at DCBA's interactive forum, CDItalk. There, you can discuss real CDI issues with real CDI professionals. While you are on the site, be sure to sign up for the free monthly CDI newsletter. Got questions? Ask DCBA!

Clinical Levels and Indicators For Malnutrition

It can be difficult to determine the appropriate way to code certain illnesses and conditions, especially as we transition into ICD-10. One of these is malnutrition, which recently came up in a discussion on the CDI discussion forum, CDitalk. Check out the discussion, join in, and share your thoughts. Also be sure to join the mailing list for the CDI newsletter, which delivers the latest industry news each month. Both the forum and newsletter are free, so what are you waiting for? Join today!

Clinical Documentation Improvement For Hospitals

CDI, as it is typically used in hospitals, utilizes consultants who assess clinical documents and provide responses to physicians, says Dr. Robert Gold, CEO of DCBA. The responses given are intended to provide solutions to issues with documentation including questions about the coding used, quality, and management of the overall care of patients. As Dr. Gold Says, “Paint the picture of the patient properly with words, so the coder can paint the same picture with codes.”

Healthcare organizations can realize positive changes in accuracy and compliance. Take a look at what this CDI Liaison Nurse had to say about working with DCBA’s team:

I am still amazed everyday at the intensity and level of cooperation with documentation from the majority of our physicians. And I don’t take credit for it. It is an expectation of the leadership here, the staff follow through willingly, and the rest just happens. The physicians are pretty accessible on the floors so we are able to make frequent contact with them and educate as needed. We even had a metabolic doc come up to us and ask how to document an unusual condition that was present on admission. Even the pediatric surgeons answer our queries. And we are presenting to the new docs coming on board at the end of the month. So life here is good.

Regardless of the feedback loop, CDI specialists can analyze queries and work with physicians on training. ICD-10 has become a motivating factor for many organizations to seek the assistance of CDI specialists. Proper documentation directly affects coding- the core of revenue and reimbursement. Accurate documentation is also essential for quality measure compliance as quality provides a foundation for care management and correct protocol procedures.

With so much to gain, many organizations have begun preparations for CDI with ICD-10 on the horizon.

Clinical Documentation Improvement Strategy

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. PCI programs can be tailored to operate with an organization’s existing program, implementing strategies where needed to help increase both productivity and profitability.

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 healthcare organizations, they bring the combined knowledge of industry professionals to find the right strategies for any organization.  

Clinical Documentation Improvement For Children's Hospitals

With so many advances in healthcare since 1979, it seems like it is about time for an update in clinical coding. With ICD-10 approaching, codes will soon seek greater specificity. ICD-10 will introduce numerous new codes, but they are welcomed in the scope of how we approach health care in the 21st century. Many healthcare organizations are seeking to improve their documentation heading into the future to increase quality and improve in other areas.

Greater attention to detail is key with coding. Communication is vital for success. By having all team members on the same page, employees can maintain accuracy and quality. When all of those involved see the benefits of pediatric CDI, they can begin to improve across the board. DCBA helps children’s hospitals with clinical documentation improvement strategies. By tailoring their approach to each client, they are able to find the correct solutions to produce your desired end result. DCBA provides educational and online resources to help pediatric hospitals documentation staff excel in documentation.

Clinical Documentation Improvement Newsletter

Looking for the latest news about the clinical documentation improvement industry? Look no further than DCBA. By bringing their experience together, DCBA has created a monthly newsletter that brings you up to date with the happenings of the industry. Sign up today and don't forget to share with your co workers as well!

How To Code SIRS Caused By Influenza

SIRS can be a difficult condition to code appropriately. With the shift to ICD-10, specialists may have difficulties with correctly documenting information. Join the latest discussion on CDiTalk and find out how to handle this condition. Also, stay in touch with the industry with DCBA's CDI Newsletter, available for free. Sign up today!