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Guest Post: Natural language processing and clinical documentation, part 2

CDI and technology

New technology heavily affects CDI and coding.

by Crystal R. Stalter, CPC, CCS-P, CDIP

Effect on coders

Once the patient is discharged, it is the coding team’s time to shine. If the hospitals’ providers and clinicians have an electronic health record (EHR) that uses natural language processing (NLP) technology, coding’s job becomes much easier. From the physicians/providers to the CDI specialists, NLP helps ensure documentation is robust, with conditions that have been queried when necessary and fully specified—producing a fully documented encounter by the time the chart crosses the coder’s desk.

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Guest Post: Natural language processing and clinical documentation, part 1

CDI and technology

Many clinicians now use dictation software and EHRs.

by Crystal R. Stalter, CPC, CCS-P, CDIP

Long before ICD-10-CM/PCS became a focus, working as a clinical documentation improvement (CDI) manager to improve physician progress and/or operative notes was a challenge—doctors either got it or they didn’t. But as the transition from paper charts to an electronic health record (EHR) began, providers started to understand how to better document their visits, since they had to choose from drop-down menus and multiple options to complete their notes. Then, as ICD-10 approached, a new awareness of medical necessity denials and revenue impact took shape. Providers began looking for ways to document better in less time.

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Guest Post: Expanding the CDI focus to the outpatient arena, part 2

Editor’s note: Crystal Stalter, CPC, CCS-P, CDIP, is the CDI manager for M*Modal in Pittsburgh. She has over 30 years of experience in the healthcare industry, with most of her focus on coding, compliance, and physician documentation. She has spent many of those years as a consultant, working with physicians and hospital HIM departments to improve their workflow processes and revenue cycles. Contact her at crystal.stalter@mmodal.com. Opinions expressed are that of the author and do not represent HCPro or ACDIS. This article was previously published in Briefings on APCs and JustCoding. This is the second part of a two-part series. To read the first part of this article, click here.

There are multiple outpatient places of service the CDI specialist can have an impact. One such place is the ED, where capture of ancillary services, start and stop times (as well as medications and dosages for injection/infusion coding), and evaluation and management (E/M) code (the codes assigned for physician reimbursement) levels often get missed or are incomplete, causing subsequent coding issues.

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