When is PHI not PHI?

There continues to be a fair amount of confusion out there when health information is PHI and when it's PII.  This is true for a number of business associates as well as hybrid covered entities.  If the health information is generated by a covered entity doing a...

Making Compliance Education and Training More Effective and Fun!

We’ve all experienced boring training where we struggle to keep our eyes open and compliance or HIPAA training is probably one of the top culprits in healthcare! Every year we’re asking to sit in front of the screen to complete hours of annual training. And is it just...

Clinical Documentation Improvement and Denial Prevention (Part 1)

Healthcare leaders have found many benefits in moving CDI professionals away from the traditional MS-DRG review model. Expansion into areas such as APR-DRG review, office based practices and quality incentives have been successful. However, only slightly more than 50%...

Coding Q&A with RMC: P codes after perinatal period

QUESTION: If a baby is older than 28 days but still has feeding problems that originated in the perinatal period, wouldn’t P92.6 still be applicable based on the ICD10 guidelines under chapter 16 that state “should a condition originate in the perinatal period, and...

CODING Q&A WITH RMC: Degenerative Changes

QUESTION: Doctors put very often “Degenerative changes are seen…” , on the XR, MRI, CT of hip, knee, shoulder, wrist, hand, foot, so on. Do we code it as DJD of the pertaining site or use code for Other specified joint disorder of pertaining site/joint like M25.851?...

Does SIRS Plus Infection Still Equal Sepsis?

Sepsis has been a hot topic for CDI specialists for years. Severe sepsis and septic shock bundles are being tracked and measured as part of the Inpatient Quality Reporting (IQR) program mandated by CMS. Therefore, the need for a clear identifications of these...

Compliance Effectiveness

On March 27th, the Department of Health and Human Services, Office of Inspector General (OIG) released a new resource guide, “Measuring Compliance Program Effectiveness”. This document (https://oig.hhs.gov/compliance/101/index.asp#measuring) is the result of a meeting...

Visibility and CDI Program Success

Clinical documentation improvement efforts have expanded well beyond the initial CMI index focus. Clear and concise documentation also ensures optimal severity of illness (SOI), risk of mortality (ROM), and can assist in several CMS quality programs. But how...