Three months from now the ACDIS team will head to our biggest event of the year—our national conference. And in case you haven’t heard it’s a milestone…our 10^th. A big number and once again we are bringing the networking, the learning, and the fun.

Since the advent of electronic medical record (EMR) systems, CDI professionals have known that physician copy and paste errors pose a threat to accurate documentation. Consequently, these errors can also negatively affect patient safety as well, according to a report from the National Institute of Standards and Technology (NIST).

A Comprehensive Error Rate Testing (CERT) study showed insufficient documentation caused the most improper payments for facet joint injections, according to the January 2016 Medicare Quarterly Compliance Newsletter.

Nearly half of the death certificates reviewed by the Centers for Disease Control and Prevention from 2009 to 2012 listed the cause of death inaccurately. The Morbidity and Mortality Report, published in January, reviewed 205 medical charts at random from eight separate hospitals in the Kansas City and St. Louis areas.

by James S. Kennedy, MD, CCS, CDIP

Even though we now have a new president of the United States who vowed to abolish the Affordable Care Act, I believe that Donald J. Trump will not touch provisions that address perceived cost inefficiency or quality within our healthcare system.

Q: If I document a wound at Stage 3 with no CC or MCC, do I also need to assign a present on admission (POA) status?
A: Every diagnosis reported (unless exempt) require a POA status.