Healthcare financial management : journal of the Healthcare Financial Management Association
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Hospitals can improve clinical documentation under ICD-10 by implementing three strategies: Bring clinical documentation improvement (CDI) specialists and coders together for daily or weekly communications to improve documentation quality, processes, and outcomes. Encourage CDI specialists to engage in direct, one-on-one conversations with physicians or generate queries, whether paper or EHR-based, to clarify missing or unclear documentation to promote better overall clinical documentation outcomes. Assess ICD-10 hot spots for documentation gaps to mitigate risk of lost revenue under ICD-10.