News & Resources

Clinical Documentation and Coding: The Foundation of Healthcare

Healthcare quality and data come from clinical documentation. Bricks and mortar are the foundation of many a structure. Clinical documentation and coding are similar, as they are also the supportive building blocks in healthcare and can be thought of as foundational as well. In healthcare, over the past 25-30 years we’ve seen the use, need, […]

We are Now in an ICD-10 World – But is Data Better?

Unfortunately, the quality of data is driven less by opportunity and more by incentives for those creating the data. Prior to the implementation of ICD-10, the key selling point of the new coding set was that it provided the opportunity for more detailed data about the nature of each patient’s condition. In theory, this improved […]

January 30: Stop CTE Awareness

CTE is coded as postconcussional syndrome which is F07.81 January 30th is National CTE Awareness Day according to This organization was founded by the family of Patrick Risha who lost his battle with chronic traumatic encephalopathy (CTE) when he was in his 20’s. This young man lived in the suburbs of Pittsburgh, Pa. and […]

A Call for Victory for HIM Professionals in 2018

For HIM and CDI professionals, 2018 looks to offer a gift of the tremendous opportunity for success. For movie buffs, the film Darkest Hour offers a tremendous view into the early days of World War II, when the fate of Western Europe hangs on the shoulders of newly appointed British Prime Minister Winston Churchill, who […]

CDI: Is Your Toolkit Well Stocked?

Hospital services must positively contribute to the revenue cycle and clinical documentation integrity initiatives. A recent outlook report released by Moody’s Investors Services spells continued ongoing financial challenges for non-profit hospitals next year. (Moody’s Survey) The firm downgrade the sector from its current stable status to negative for 2018, attributable to a wide variety of […]

Cardiovascular and Vascular Interventional Radiology Specialization Improves Coding Performance

Product Headline: 2018 Cardiology Reimbursement & Compliance Update Product Image: Product Link: Learn more A deep dive into the “toughest type of coding. While you may have dedicated CPT® coders for interventional cardiology (IC) and vascular interventional radiology (VIR) for outpatient coding, you may not have considered the importance of doing the same for inpatient […]

ICD-10 Coding: Three Ways to Improve Quality: Consistency, Collaboration, and Education

Quality coding plays a critical role in protecting revenue and reducing operational costs. Results of the 2nd Annual National Coding Productivity and Accuracy Contest were released in September 2017. Although accuracy rates were higher than reported following the same contest in 2016, quality remains significantly low compared to the 95 percent benchmark established in ICD-9. […]

MACRA, MIPS, and APMs: Why is CDI an Essential Ingredient to the Alphabet Soup?

Quality of clinical documentation and ICD-10 diagnosis code accuracy and specificity are essential under MACRA. My presentation at the 2017 American Health Information Management (AHIMA) convention stressed the need for understanding a basic overview of the Medicare Access and CHIP Reauthorization Act (MACRA) and its performance categories. These performance categories and quality measures are important […]

Coding Diabetes: Time to Look at the Coding Guidelines Again

November is National Diabetes Awareness Month, prompting coders to review the coding guidelines for this disease suffered by more than 10.9 million U.S. residents. During November, the Centers for Medicare & Medicaid Services (CMS) is raising awareness about diabetes, diabetic eye disease, the importance of early disease detection, and related preventive health services covered by […]

COPD, Sepsis Among Conditions Creating Coding Dilemmas in New AHA Coding Clinic

AHA Fourth Quarter Coding Clinic identifies problematic diagnosis codes. Hopefully the subject of the most recently published Coding Clinic will not be too scary to discuss. It is effective for discharges from Oct. 1, 2017 forward. The majority of this issue (94 of the 111 pages) provides some background to the new and revised ICD-10-CM/PCS […]