Posts about

coding

I have a clinical background and want to become a CDS; do I need a coding qualification?

Nour Alatari May 20, 2024
In the intricate world of healthcare, Clinical Documentation Specialists (CDSs) play a vital role in ensuring patient records are accurate and..

CDI Strength: Beat Risks, Boost Sustainability

Mike Kertes March 27, 2024
In the ever-evolving landscape of healthcare, Clinical Documentation Improvement (CDI) stands out as a critical pillar, ensuring the accuracy,..

CDI Queries Work Best if the Recipient is Kept in Mind

Dr Erica Remer March 13, 2024
I had an epiphany the other day while discussing compliant query composition with a very knowledgeable clinical documentation integrity specialist..

A CDI Year-In-Review

Mike Kertes December 7, 2023
Reflecting on the past year in the realm of Clinical Documentation Improvement (CDI), particularly in countries using ICD-10-AM and AR-DRGs, it's..

Reflecting on CDI 2023 - Harnessing Momentum: A Turning Point for Clinical Documentation Improvement (CDI)

Mike Kertes September 19, 2023
As I sat on the plane on my return flight home from the Gold Coast, I couldn't help but feel a sense of pride and elation to be a part of something..

Clinical Documentation Improvement- a nursing role?

Joanna Forteath July 31, 2023
This article was first published in the Australian Nursing & Midwifery Journal (ANMJ) Jul-Sep Volume 28, No. 1 and has reproduced with consent. If I..

'What the Heck is This?' Written Documentation Queries: A Clinician's Perspective

Dr Felicity Sinclair-Ford May 26, 2023
What do we want? Clinicians who document efficiently and thoroughly, specifying diagnoses, linking them to interventions, and including pertinent..

A Tale as Old as Time: Heart Failure & Fluid Overload Part 2

Dr Felicity Sinclair-Ford December 13, 2022
In the last instalment, Dr Felicity Sinclair-Ford went on a quest to find all the coding standards and advice relevant to heart failure and fluid..

"Due To" Methylene Blue: A CDS Goes Down the Rabbit Hole

Cheryl Fenwick Evans December 2, 2022
Working as a CDS in the cardiovascular department, Cheryl Fenwick Evans saw a diagnosis she wasn't familiar with. Determined to know more, she dug a..

CDI News USA: Texas hospital to pay $3 million in whistleblower case

ACDIS September 10, 2021
A case from America illustrates the serious consequences of upcoding.