December 2021 Newsletter

Inpatient vs. Observation ‑ It’s All in The Patient Story

When a clinical decision is made by the physician or other provider to hospitalize a patient, he/she must decide the level of care designated by “Inpatient” vs. “Observation.” While the type of care is identical in nature whether inpatient or observation, there are certainly potential costs implications for the patient in terms of financial responsibility for copays and deductibles. For instance, patients are generally responsible for all self-administered drugs when placed in observation status.


July 2019 Newsletter

Does CDI Play A Role in Establishing Medical Necessity?

The question of whether CDI plays a role in the establishment of medical necessity surfaces in my discussion with my colleague physicians and fellow CDI professionals. Medical necessity is a hot issue right now as third-party payers continue to focus upon denial of payment for hospital inpatient level of care or are only approving hospital level of care as an observation patient with the goal of enhancing their bottom line.


June 2018 Newsletter

A Vision of CDI That Inspires Physicians & Others in the Care Team

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...


March 2018 Newsletter

Cut and Paste in the EHR is Problematic for Many Reasons

The electronic health record serves first and foremost as a communication tool for patient care, facilitating fully informed coordinated quality care. One functionality of the record intended to save time and energy, the cut and paste and carry forward functionality of the record has the real potential to degrade the quality and usefulness of the recorded information within the record. Patient care, quality and safety of the patient are significantly jeopardized.....    


February 2018 Newsletter

Clinical Documentation Improvement-A Path for Success:

Clinical Documentation Improvement Specialists have a responsibility to continually advance and grow their careers through self-education, attendance at webinars, in-person conferences and teleconferences, possessing an insatiable appetite for learning and expanding their breadth and depth of knowledge in principles of clinical documentation...