Clinical Documentation Improvement and Coding During a Pandemic: Three Lessons Learned on the Front Lines

AHIMA February 23, 2022
Emmel B. Golden Jr., MD, FCCP, CCDS

COVID-19 has prompted a look-back on my experience working as a pulmonary critical care physician for more than three decades, specifically during three infectious disease pandemics: HIV/AIDS, H1N1, and COVID-19.

Although AIDS, H1N1, and COVID-19 were vastly different, one commonality stands out: Physicians create the clinical story. It is their documentation that provides the narrative.

In the clinical story, the plot and themes of the patient’s condition unfold. And, in my experience, it is also where the true nature of a pandemic is exposed.

Increasingly, coding professionals and clinical documentation improvement (CDI) professionals help physicians tell that story by guiding them and ensuring their documentation translates to accurate coded data. The value of these efforts cannot be underestimated. Coding and...

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