Clinical Documentation Improvement
A coding query is a communication tool or process used to clarify documentation in the medical record to support accurate diagnosis and procedure code assignment. This guide summarizes best practices taken from nationally recognized CDI standards.
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The alignment of UM and CDI has shifted from a best practice to a financial imperative. When these teams operate in silos, gaps in medical necessity rationale, clinical validation, and admission status decisions become fertile ground for denials.
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CMS requires all providers to maintain a comprehensive medical records program that protects the integrity, confidentiality, and accessibility of patient records. Whether your facility was just cited or you’re proactively strengthening your compliance efforts, our RHIA and RHIT experts are equipped to guide your team through the entire process.
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Clinical documentation specialists serve as the essential link between providers, coding professionals, and compliance teams. But how do we train CDI specialists to succeed in such a high-stakes, detail-oriented environment?
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Hospitals and health systems need to strengthen their DRG coding validation, documentation workflows, and appeal strategies to safeguard their reimbursements. Here are some best practices and other helpful insights to help your team stay ahead.
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Physician burnout is a growing crisis in healthcare. However, medical coders and CDI professionals can play a vital role in alleviating some of these pressures, helping to create a more sustainable work environment for providers.
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Clear, thorough, and descriptive outpatient medical coding documentation is the cornerstone of proper reimbursement and patient care. Here are the essential documentation guidelines for outpatient medical coding, drawing on our own best practices and industry expertise.
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There is a notable scarcity of compliance plans specifically tailored for provider-entered charges. We address this gap and provide a comprehensive framework for implementing robust charge entry compliance plans for physician groups.
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How do you shape the future of an accurate Inpatient, Outpatient, or Profee coder? With several best practices that have been thoroughly tested by a team of real-world coding and auditing experts who have 20+ years’ experience in HIM.
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The challenge of coding uncertain diagnoses in the complex Inpatient landscape looms large, demanding a nuanced approach to ensure accuracy and compliance. Review our specialized services to help you navigate uncertainties in the coding process.
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