Author Archives: Sharon

DOCBytes: Ambulatory CDI…Do You “SEE” Yourself?

DOCBytes There has been more buzz than ever about starting an ambulatory CDI (Clinical Documentation Improvement) program. First of all, let me begin with saying in some circles you’ll hear ambulatory CDI and in some outpatient CDI. Ultimately they refer … Continue reading

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Refueling the Passion for your Profession

DOCBytes – Special edition I received a call today from a very passionate and well-informed HIM professional. At first, we were discussing where our profession is going and what credentials would be suitable for her going forward. As we continued … Continue reading

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Making Your EHR Documentation More Audit-Proof: The Era of the Trojan Horse

DOCBytes I’m back continuing simple Documentation Bytes; DOCBytes, for you to apply to your everyday world. The last post was so popular I thought it may be beneficial to provide a little more on EHR (electronic health record). We have … Continue reading

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“The EHR Is and Isn’t your friend?”

Utilizing the EHR (Electronic Health Record) offers the providers, greater access to patient information, improved patient care, care coordination, and potential for cost savings.  There are also challenges this documentation tool can bring to the provider in terms of documentation. … Continue reading

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“Okay Doc, Take A Seat…May I Help You?”

I have worked with many physicians over the years and have developed great relationships with quite a few. As I share information through work engagements, presentations or just chatting, we both often leave the conversation with a new perspective on … Continue reading

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Fitting Coding and CDI into MACRA

Back in 2014, I wrote an article called “Holistic Collaborative Documentation,” published in RACMonitor.  The thought behind that article was about not only how important physician documentation is within any setting but also about the need for coders and CDI … Continue reading

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Were We Asleep at the Wheel? Changes to the Official Guidelines for Coding and Reporting 2017

Yesterday was certainly like any other, in the world of healthcare coding, clinical documentation improvement (CDI) and appeals. The work is intriguing, interesting, and certainly a learning experience every day. The only thing that made this day different was taking … Continue reading

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Documentation and The “CMS Quality Strategy 2016”

“CMS Quality Strategy 2016” was released by CMS (Centers for Medicare and Medicaid Services) in November 2015. As evidenced by recent changes in the OPPS Final Rule 2016 and other quality and value-based trends, movement has been aggressive and persistent … Continue reading

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The “Building Blocks of Documentation”: Cornerstone I: State of Disease

As providers venture into the world of new payment models and methodologies, having the tools to do that seamlessly and knowledgably is critical for success. Understanding and implementing the “Building Blocks of Documentation” can be a crucial first step in … Continue reading

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“The Building Blocks of Documentation” for ICD-10

A couple of years ago, circa 2013, when CMS (Centers for Medicare and Medicaid Services) unveiled “The 2-Midnight Rule” and the need to certify the inpatient admission, the “5 W’s for Documentation/Auditing” were born. This laid the framework for the … Continue reading

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