Podcasts about clinical documentation improvement

In this episode of HIPcast, Glenn Krauss, shares his experience in Clinical Documentation Improvement across the country. Glenn also challenges the future role of the HI Professional in CDI and the evolving Physician Documentation Excellence programs. #HIPcast with Shannan and Seth.HIPcast brought to you by Enterprise Social Record Show Sponsor:DocuVoice - FaircodeLearn more at https://www.faircode.com/Steve Hansen – steve@docuvoice.com or 615-600-2166

YOUTUBE VERSION https://youtu.be/u_u3CCWa_zA WWW.DOCUCOMPLLC.COM Dr. Stokes is a graduate of Meharry Medical College in Nashville, Tennessee. He completed internship and a residency in Family Medicine at the University of Mississippi Medical Center in Jackson, Mississippi. Dr. Stokes has served as a consultant for numerous hospitals, primarily focused in the areas of physician advisor, utilization management and clinical documentation improvement. CLINICAL DOCUMENTATION IMPROVEMENT & INTEGRITY INSTITUTE (C-CDI) The Clinical Documentation Improvement & Integrity (C-CDI) Institute is dedicated to significantly improving the competency in clinical documentation within health care to capture the complete severity-of-illness being managed and appropriately justify the consumption of resources within today's regulatory environment. The C-CDI Program provides the premier educational seminar dedicated to explicit Clinical Documentation Improvement.

In this week's show, John interviews Dr. Christian Zouain. Christian first appeared in Episode 77 to discuss how he landed his first job in Clinical Documentation Improvement (now usually referred to as Clinical Documentation Integrity). During our interview, he shares his advice for landing your first job and mentions resources not discussed in his first appearance. He also describes how the industry has changed, and how to advance professionally in the industry. He reminds listeners that it is possible to find a career in this field even if you have not completed residency. And he closes by inviting listeners to contact him for advice and to find out about open positions at his employer You will find all of the links mentioned in the episode at nonclinicalphysicians.com/hospital-cdi-career/                                                            =============== You can support this podcast by making a small monthly or annual donation. To learn more, go to nonclinicalphysicians.com/donate You can now join the most comprehensive Community for all clinicians looking for a nontraditional career at NewScr!pt. Get an updated edition of the FREE GUIDE to 10 Nonclinical Careers at nonclinicalphysicians.com/freeguide. Get a list of 70 nontraditional jobs at nonclinicalphysicians.com/70jobs.

Join Jaci Kipreos, Kelly Shew and Melissa Kirshner for a discussion in Clinical Documentation Improvement (CDI).  This channel features videos about AAPC, the leader in certifications for the business of healthcare. If you're looking to start a new career, an AAPC certification as a Certified Medical Coder (CPC) can land you a job with a 55k salary in as little as 120 days. AAPC offers lots of certification options. To get started, go to https://www.aapc.com/training/medical-coding-training.aspx Follow AAPC on LinkedIn: https://www.linkedin.com/company/206425/ Like AAPC on Facebook: https://www.facebook.com/AAPCFan/ Follow AAPC on Instagram: https://www.instagram.com/aapc_official/ Follow AAPC on Twitter: https://twitter.com/aapcstaff

It's not easy moving into Clinical Documentation Integrity as a new nurse or coding professional. But now imagine what it's like if you're from Maryland. And it's 2006. These were pre-ACDIS days, in a state which used APR-DRGs. In other words, no best practice, little information, and no real community. But Dawn Diven, Enterprise System Director of Clinical Documentation Improvement for WVU Medicine, is used to taking on difficult challenges—and overcoming them. And she's got a track record to prove it. Which you'd never know because she's also humble and down to earth as they come. On this episode we discuss: How one survived (and thrived!) in CDI in the stone age that was 2006, in Maryland of all places. Hint: Networking is key. Dawn's career progression and leap into leadership in 2016 The lay of the land at an ever-changing WVU program: Implementing assistive software (a two-year process from approval to adoption!) and a CDI career latter The struggles of being an early adopter of outpatient CDI How to build a business case: Where to start, how to do it, and Dawn's secret sauce for 100% success rate, to date A revealing look at some of her struggles and failures The difficult reality and compromises inherent in leading a team A classic rock hit that I can't believe didn't make the OTR Spotify playlist ... until now.

The compliance and coding worlds are filled with acronyms – and we've got another one for you: CDI. That stands for Clinical Documentation Improvement, and it's a crucial piece of the healthcare puzzle. We invited Joanne Spethman, a Coding, CDI, and HIM Consultant, to share insights from her 30+ year career in inpatient and professional coding, CDI and HCC auditing on our latest episode of Compliance Conversations.

This episode of our award-winning podcast continues examining the impact of risk adjustment models and methodologies. Knowing the models and their updates is crucial to full reimbursement for the patient's care.   Moderator: Tomas Villanueva, DO, MBA, FACPE, SFHM Senior Principal, Clinical Operations and Quality Vizient   Guest: Jim Tamburini, BS, RHIT, CCS, CCS-P, CDIP Senior Consulting Director, Clinical Documentation Improvement and Coding Vizient   Show Notes: [00:47] Variables and POA [03:03] Heart failure [04:00] Changes in the COVID model and pediatric COVID model [04:57] Document completely; MEAT (monitor, evaluate, assess, and treat) [06:28] Clearly delineate POA conditions from conditions acquired after admission [07:01] The Problem List   Links | Resources: To contact Modern Practice: modernpracticepodcast@vizientinc.com Jim's email: james.tamburini@vizientinc.com Vizient clinical documentation improvement site: Click here   Subscribe Today! Apple Podcasts Amazon Podcasts Android Google Podcasts Spotify Stitcher RSS Feed

This episode is the second installment about Clinical Documentation and Coding. Today, we have a conversation about Clinical Documentation Improvement with Amber Malone-Wright, Director of Clinical Documentation Integrity at CHESS Health Solutions. I want to pick your brain about clinical documentation improvement also known as CDI. So tell me amber what is CDI all about?Well Thomas, I think the main message about CDI is around quality initiatives. Most people who ask providers why good clinical documentation is necessary, many of them are going to say that it's important for the communication to other providers about the continuity of care. Physicians generally understand the need to make documentation legible, timely, complete, and clear and you know with electronic medical records a lot of that is resolved. They also understand that documentation is a legal health record. They understand the common phrase - if you didn't document it, it didn't get done. CDI programs have increased significantly over the past ten years and are predominantly used in the inpatient hospital setting. But now this is expanding into the ambulatory and provider office setting due you value-based care and contract changes. The key is to really just engage providers to correlate how clinical documentation provides an opportunity to demonstrate the quality of care that was provided during an office visit. The American Health Information Management Association or AHIMA really says it best. They say the message to physicians should be: simple good clinical documentation will improve communication, increase recognition of comorbid conditions that are responsive to treatment, and validate the care that was provided, and show compliance with quality and safety guidelines. Why should a provider change their documentation?So physicians are taught to ask why as part of a diagnostic training that they went through and the need to understand the reason for a change in clinical documentation in order to fully embrace the concept. So if a provider challenges a CDI recommendation, it's an opportunity to explain why CDI is necessary. Explain the concept around whether it's MSDRG for inpatient or value-based care contracts and how they're designed to increase reimbursement for care of complex patients. It's also important to explain the severity or the illness or risk or mortality score that's derived from the codable diagnosis codes. It's also important that providers understand the process of audits and denials and financial impact. Not only for hospitals but the outpatient office visits as well. Documenting all of the chronic conditions that are known for the patients that affect the care and treatment for that patient impact the medical decision making by the provider and can also impact the level of evaluation and management services.Amber, tell me how a provider can implement CDI into their workflow?Electronic medical record technology has really improved the ability for medical records to be legible and timely. Physicians generally use structured templates to input documentation or they can dictate in a standard progress note format. But sometimes, the benefits of the electronic documentation are not always great. Sometimes there are significant challenges with electronic documentation, such as copy and pasting documentation, which can increase the risk of audits including outdated problem lists and then the inability for providers to find the correct diagnosis code in a drop-down selection. It's important to remember that providers are not trained in coding, yet many providers now know the codes that are important for their billing. If the provider chooses a nonspecific diagnosis code to include in the medical record, it could potentially make it more difficult for someone to code the case with a more specific diagnosis code. The EHR creates the opportunity to...

There are six domains of health care quality outlined by the IOM (Institute of Medicine.) These include Safe, effective, patient-centered, timely, efficient, and equitable. Fran Jurcak, Chief Clinical Strategist, Iodine Software, and Deborah Jones, Director of Clinical Documentation Improvement at Brigham and Women's Hospital, spoke with Lauren Hickey on how documentation accuracy can help achieve quality processes and outcomes in health care. People want to go where they are going to get the best care, so having the ability to determine which hospitals offer optimum quality is essential. “All of this documentation translates into publicly reported information that is driving hospital reputation and consumer decisions about where they will receive care,” Jurcak said. “It's about ensuring that the world can see the level of care you provide, and what level of acuity patients are experiencing, and whether or not they have positive outcomes.” More and more, these quality outcome metrics and reimbursement are tied together. Penalties, payment, and accreditation withholdings could occur if healthcare organizations do not meet specific benchmarks. Without proper accreditation, healthcare organizations may not be able to offer certain services. Jones said that in Boston, where Brigham Health is one of many renowned healthcare institutions, they constantly need to prove to their consumers that they are delivering the best care. “First and foremost, it's about documentation accuracy; ensuring the basic CDI, that all conditions are being monitored and treated are capturable.” Improvements in quality ranking and scoring of documentation allow systems to capture an accurate patient's clinical picture. “There are conditions that are now important to these methodologies in terms of identifying risk that historically in the documentation world we didn't worry about,” Jurcak said. “Today, it's about capturing the true clinical picture about what's happening to patients so you can best reflect yourself as an organization to the outside world.” Iodine created a documentation accuracy index to determine if what's in the medical record is happening to the patient. This index can solve documentation issues, close gaps, and increase reimbursement.

In this program, Michelle McCormick, Revenue Integrity Director, Clinical Documentation Integrity and Mark LeBlanc, Manager Clinical Documentation Integrity, both at Stanford Health, discuss how they shaped their successful CDI program through the fundamentals of prioritization, clarity and transparency.   Guests: Michelle McCormick, RN, MBA-HCM, BSN, CCDS, CCS, CRCR Revenue Integrity Director, Clinical Documentation Integrity Stanford Health   Mark LeBlanc, RN, MBA, CCDS Manager, Clinical Documentation Integrity Stanford Health   Moderator: Marilyn Sherrill PI Program Director Vizient   For more information, email picollaboratives@vizientinc.com   Show Notes: [00:00 – 01:56]  CDI prioritization [01:57 – 03:09]  When prioritizing DRG's look for the unusual. [03:10 – 05:05]  Clarity within the reporting process [05:06 – 06:30]  Transparency and how it shapes future improvement initiatives [06:31 – 07:56]  Feedback from their physician partners [07:57 – 09:18]  Meaningful response rate advantages [09:19 – 09:43]  Don't try and boil the ocean   Disclaimer This presentation is intended for educational purposes only and does not replace independent professional judgment. The statements and opinions expressed are those of the speakers and, unless expressly stated to the contrary, do not represent the views or opinions of Stanford Health Care.  Stanford Health Care does not endorse or assume responsibility for the content, accuracy or completeness of the information presented.   Subscribe Today! Apple Podcasts Amazon Podcasts Spotify Google Podcasts Android Stitcher RSS Feed

How would you like to still use your medical knowledge and keep learning new things, but not be stressed out by the challenges of patient care? If so, being a CDI specialist might be just the ticket. Today I'm speaking with Dr. Jenn Jolley, a general surgeon who put the scalpel down to work in Clinical Documentation Improvement so she could still use her medical training but have more family time. Come find out why she left surgery, what her day-to-day is like, and how to explore this flexible career path. You can find the show notes for this episode and more information by clicking here: www.doctorscrossing.com/50

Nonclinical Nation, it has been a long time since we have heard about clinical documentation improvement as a nonclinical career. And I thought it was time to revisit this topic. In fact, there are many interviews from early in the podcast that are worth revisiting. So, I decided to bring back some of them during this summer of 2021. We'll post several of these in the coming months, interspersed with new episodes, as a way to revisit popular nonclinical jobs with awesome guests.  The first blast from the past this summer is my interview with CDI expert Dr. Cesar Limjoco. Getting Your First CDI Job I enjoyed revisiting my conversation with Dr. Limjoco. He is very passionate about what he does. We really got into the core principles of CDI. And Cesar outlined the basic steps for pursuing such a career. Here they are: Get involved at your hospital on a voluntary basis with the appropriate committees and offer to help with CDI projects. Join professional organizations such as the Association of Clinical Documentation Improvement Specialists, the American Health Information Management Association, and the National Association of Physician Advisors. Take on a paid part-time position as CDI Physician Advisor as you continue your learning process. Expand your responsibilities to full-time if that's your goal. All of the links for the episode can be found at nonclinicalphysicians.com/clinical-documentation-improvement. If you'd like to join my NEW Nonclinical Mastermind Group opening this fall, you can learn about it and join the waiting list at nonclinicalphysicians.com/mastermind. Get an updated edition of the FREE GUIDE to 10 Nonclinical Careers at nonclinicalphysicians.com/freeguide. Get a list of 70 nontraditional jobs at nonclinicalphysicians.com/70jobs. Check out a FREE WEBINAR called Best Options for an Interesting and Secure Nonclinical Job at nonclinicalphysicians.com/freewebinar1

Erkeda DeRouen talks to Dr. Liz Aguirre, MD, CCDS. Liz is a board-certified Internal Medicine physician with ten years of experience in hospital medicine and six years of Clinical Documentation Improvement experience. An educator to physicians, nurses, and students, Liz is passionate about person-centered wellness, focusing on mental and spiritual health. She is an established speaker with a specific passion for speaking about personal wellness to maximize the quality of life and work performance. In this episode, Erkeda talks to Dr. Aguirre about her atypical path to medicine, the social determinants of health, and the importance of positive self-talk. [00:35] Introducing Dr. Liz Aguirre, MD [06:40] Getting into Medicine [10:14] Social Determinants of Health [13:35] Wellness in Healthcare Workers [21:03] Getting Unstuck through Prioritizing Wellness [24:30] Hospitalists and Nocturnists [28:07] Dr. Aguirre’s Advice to Pre-meds and Medical Students Full show notes

Hosts: Henry Sullivant MD, Chief Medical Officer; Jake Lancaster MD, Chief Medical Information Officer Guest: Vicki Brown, Director of Clinical Documentation Improvement Music by: Hank Sullivant Learn about what a CDI seeks to accomplish. Understand what metrics documentation affects Understand benefits of CDI to providers as well as to health care systems CME Credit Info: Link to complete brief survey and claim CME credit - https://www.surveymonkey.com/r/C55LKSY (https://www.surveymonkey.com/r/C55LKSY) CME credit is available for up to 3 years after the stated release date Contact CEOD@bmhcc.org if you have any questions about claiming credit. Faculty Disclosure: None of the hosts or guests have relevant financial interests to disclose. It is the policy of Baptist Memorial Health Care Corporation (BMHCC) to promote balance, independence, objectivity, and scientific rigor in all educational activities; to require disclosure of relevant financial relationships from individuals engaged in content development or planning of a CME activity; to identify and resolve conflicts of interest related to those relationships; and to make disclosure information available to the audience prior to the CME activity. Presenters are required to disclose discussions of unlabeled/unapproved uses of drugs or devices during their presentations.

In this episode of the HealthBiz Podcast, ChartWise Medical Systems CEO, Steven Mason shares his journey from New Orleans to Nashville, explains how his background in organizational development and consulting prepared him for corporate leadership, and opines on the impact of President Joe Biden’s Administration on healthcare.We discuss CDI: clinical documentation integrity, and how it’s shifting as payment models get more complex and COVID-19 upends traditional care patterns.

What did you think of the podcast? Drop a line to host Dan Kelly at dan.kelly@ahima.org.

In this podcast, two leaders from Ensemble Health Partners - Staci Booth, Director of Coding Education, DRG Validation, and Appeals and Kathryn Vermillion, Senior Director of Clinical Documentation Improvement - discuss COVID-19 and the pandemic's potential long-term impacts for the healthcare industry. This podcast is sponsored by Ensemble Health Partners

This week I present my conversation with cardiac surgeon Robert Applebaum, who successfully pivoted to a satisfying nonclinical job after a long and successful clinical career. It was fun to catch up with a friend and colleague who I’ve known for years. We both come from the same hospital where we collaborated on quality improvement initiatives, me as CMO and Rob as Director of the Open-Heart Program. After a prductive clinical career, like other physicians in physically and mentally demanding surgical specialties, Rob wanted to navigate to a less intense, yet meaningful, career. In today’s episode, he describes his thought process and the path he followed during this critical time. Rob Applebaum is now a Physician Advisor at AMITA Health. He works on utilization managment, quality initiatives, and with the Clinical Documentation Improvement program at the hospital. And he finds the work very rewarding. To hear all of the details and download a transcript, go to vitalpe.net/episode132

As reported by ICD10monitor, the World Health Organization (WHO) has classified physician burnout as an occupational phenomenon, while noting that it is not a medical diagnosis. There are some estimates that more than half of physicians have experienced burnout. But what do coders and clinical documentation integrity specialists (CDISs) need to know about burnout among their physicians? Reporting our lead story during this edition of Talk Ten Tuesdays will be Megan Cortazzo, MD, Medical Director for Clinical Documentation Improvement and Health Information Management at UPMC and Assistant Professor of Physical Medicine and Rehabilitation. Joining the conversation on burnout will be nationally prominent psychiatrist H. Steven Moffic, MD. The live broadcast will also feature these other segments:The Coding Report: Laurie Johnson, senior healthcare consultant at Revenue Cycle Solutions, LLC, has the Talk Ten Tuesdays coding report.RegWatch: Stanley Nachimson, former Centers for Medicare & Medicaid Services (CMS) career professional turned well-known healthcare IT authority, reports on the latest regulatory news coming out of Washington, D.C. News Desk: Timothy Powell, compliance expert, and ICD10monitor national correspondent, anchors the Talk Ten Tuesdays News Desk. TalkBack: Erica Remer, MD, FACEP, CCDS, founder and president of Erica Remer, MD, Inc. and Talk Ten Tuesdays co-host, reports on the latest coding and documentation issue that has caught her attention.

Host Dan Kelly chats with AHIMA speakers and HIM Practice Excellence Directors Tammy Combs and Patty Buttner about next week's CDI Summit and CDI Trainer Workshop. There's still time to register for both! http://ahima.org/events/2019cdisummit http://ahima.org/events/2019CDITrainerworkshop

Glenn Krauss, founder of Core-CDI.com discusses the state of the industry and suggests some changes.

With special guests Pauline O'Dowd, RN, BSc, CCRN, CCDS, CDIP, managing director of CDI at Huron Healthcare in Chicago, IL, and Gerri Birg, MSN, RN, CCDS, the national lead for Huron's Clinical Documentation Improvement solution practice.  Co-hosted by Penny Richards, coordinator for the ACDIS Certified Clinical Documentation Specialist (CCDS) credential program.  To learn more about the CCDS certification, please visit https://acdis.org/certification.

With special guest Susan Schmitz, JD, RN, CCS, CCDS, CDIP, Regional Director of Clinical Documentation Improvement for SCAL Kaiser Permanente in Pasadena, California. Co-hosted by Allen Frady, RN, BSN, CCDS, CCS, CDI Education Specialist for ACDIS.  To read the 2019 Medicare Advantage and Part D Rate Announcement and Call Letter as featured on "In the News," please click here. To learn more about the 11th annual ACDIS conference and 10 reasons to attend, please click here.

Don Hall, CDI Coordinator for University Medical Center in Las Vegas, Nevada reviews the success they are seeing since making recent changes in their CDI program

Interview with Heidi Hillstrom, reveals keys to her success with the CDIS program at St. Luke's in Duluth, Minnesota.

In this episode, John interviews Dr. Cesar Limjoco, a nationally recognized expert on CDI (clinical documentation improvement). There is a growing demand for CDI Medical Advisors in the U.S. because of complex coding rules.