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What should you call that elevated Creatinine? That's the easy question. But what is their baseline?! That's tougher. A thread 🧵

🚨Is your hospital making this mistake?🚨 Auditing for joint commission documentation requirements that don't exist. The Joint Commission defers many documentation requirements to an institution's own bylaws. The AMA (and therefore CMS) updated E/M requirements for

Uh oh. Do we need to pump the breaks a bit? CDI efforts (though well meaning) may have nudged providers a bit too far in calling almost every confusional state "encephalopathy" in the race to assign MCCs and CCs. Remember: 👉 Altered Mental Status is not a diagnosis. It’s a

People read your note for information pertinent to them, and your audience is diverse. Make your note searchable to the eyes. This is best done with 🔷 Headlines 🔷 Short Lists 🔷 Bulleted points Plus, this is more efficient for you to edit the following days and less

Many CDI educators miss this point about risk-adjustment: Providers don't know the basics of coding. They often don't know that: 1. Diagnoses must be documented during THAT inpatient encounter to be coded. 2. Diagnoses cannot be captured from automated problem lists 3. Most

I'm not Harry Potter. Neither are you. When we've recommended providers document “Down to and INCLUDING bone” for debridements, we'll get a rebuttal like: “But when I went TO Florida, I was IN Florida!” Here’s a better analogy: In high school, my coach punished us with

When checking boxes falls short: A patient comes in with crushing chest pain. 👉 They have ST elevations on EKG. 👉 And their troponins have the appropriate rise and fall. Cardiac angiogram shows clear coronaries but... is actually consistent with Takotsubo cardiomyopathy

Is it enough to call it a concerning trend? I heard it form a neurointensivist. I heard it from a CDI Physician Advisor. I heard it from a vendor. They all said CDI was starting to get a bad reputation at their hospitals. Each one named a similar inciting event: 👉 Someone

Is CMS's new "Failure to Rescue" surgical complication death-rate metric an enigma to you? Well, with the help of some friends, I took a swing at finally understanding it. In tomorrow's newsletter, I'm simplifying it for you and sharing a few things I learned (and couldn't

I spent TOO MUCH time researching the Failure-to-Rescue measure so you don't have to. Seriously, save yourself the time. You can get lost in the weeds. Just read my newsletter👇 (But I include links to the deep stuff if you're so inclined) Check it out here:

Malnutrition denials are increasing with payers using GLIM criteria while ignoring ASPEN criteria. However, from the 5-year update regarding GLIM from the Journal of Parenteral and Enteral Nutrition published April 14 2025: "...the GLIM consensus approach was mainly intended to

I'm seeing denials that are simply divorced from medical reality. Two recent examples: •“Lethargy is not terminology utilized in the routine description of encephalopathy,” and •“Lethargy means fatigue or lack of energy.” When the credentials, let alone a name, of the

One of the most overlooked specialties in CDI? Anesthesiologists. Tomorrow’s newsletter includes: 👉 The hidden value (and pitfalls) in anesthesia documentation 👉 Why ignoring it might be costing you in risk adjustment and reimbursement 👉 The eye of Sauron 👉 Sarah Mclachlan

In today’s newsletter, I broke down: ✅ Why anesthesia notes matter ✅ Two systemic EMR issues no one’s talking about ✅ Commonly missed diagnoses ✅ How to bring anesthesia into the CDI conversation (hopefully without starting a war) Read it here → droubredigest.beehiiv.com

Well this is cool. Follow up to a tweet 3 years later! Find your identity outside of medicine!

How your health system may be missing a massive opportunity: Anesthesia (nice article by Dr. Robert Oubre): droubredigest.beehiiv.com/p/anesthesia-c… via @dr_oubre