Listen to Glenn cover various points in the CDI arena. You can check out the website this podcast is featured on here.

I am thrilled to welcome Dr. Maria Mirt to the latest episode of the No Fears CDI Podcast! Maria joins us at the fascinating crossroads of primary care, operations, and clinical documentation integrity (CDI). Her insights are both practical and inspiring, especially for clinicians and practice leaders navigating today’s documentation demands.

The Ideal State of CDI- Collaborating Synergistically With All Other Ancillary Healthcare Roles to Achieve Real Meaningful Improvement in the Communication of Patient Care. Let’s Not Forget the Patient in any CDI Initiative. Reimbursement is a byproduct measure of documentation improvement that is sustainable over time. Rather than CDI specialists focus primarily upon capture of diagnoses, i.e., CC/MCC, principal diagnosis shift, HAC and PSI clarification

A recent conversation with a CDI colleague of mine raised several interesting points I would like to share for consideration. We were discussing an initiative where the CDI specialists and their department were going to transition to working on the floor reviewing records with the intent of conversing more with the physicians and residents on documentation improvement opportunities. The impetus of the initiative to transition to the floor was to be more readily

Clinical documentation improvement spans the entire continuum of care from the time the patient presents to the Emergency Department or is direct admitted to the hospital until the time of patient discharge and the completion of the discharge summary. The CDI specialist’s role in enhancing the quality, completeness and effectiveness of clinical documentation is to recognize and treat the record as a communication tool as opposed to a reimbursement tool.

Clinical documentation improvement has evolved over the last ten years with the advent of the electronic health record and the ability to use natural language processing and other key software to enhance the overall efficiencies and effectiveness of medical record chart reviews. This facilitates the identification of opportunities for diagnoses reporting, hospital acquired conditions and patient safety indicator clarifications. As a whole the profession has not kept up

Complacency is the main contributing factor that leads to suboptimal performance and achievement of sustainable operational processes and outcomes for any business. Clinical documentation improvement programs have discounted the necessity to evolve with the times, overlooking critical opportunities to contribute to the overall welfare of the healthcare delivery model. A strong CDI program for the right reasons with an underlying commitment to achieving

Most Clinical Documentation Integrity (CDI) programs are mislabeled and misidentified in the present format. Integrity is defined as the quality or state of being complete or undivided per Merriam-Webster. A few years back the association representing the Clinical Documentation Improvement Specialist’s community elected to replace the “Improvement” part of the name to “Integrity”, now referred to as Clinical Documentation Integrity Specialists.

I recently talked with a colleague on the phone who has been out of work for over a year now, this despite the fact the economy is performing well on all major indices. Now, granted my colleague has her age going against her as a strong headwind, she has been actively searching for a book-keeping related position day in and day out with little results. My colleague has been a bookkeeper for over twenty-five years with a very stable work history, having been at her last

CMS under its Medical Review Policy holds its contractors such as the Medicare Administrative Contractors responsible for insuring the payment of provider claims accurately with the primary mission of reducing provider billing errors. The primary goal is to pay the claims correctly the first time around. MACs review clinical documentation to prevent improper payments and choose claims for review based on many factors such as the service specific improper payment rate,