The proposed rule changes for the Conditions of Participations (CoP) were recently finalized. They include some relief regarding rules for physicians signing, dating, and timing verbal orders within 48 hours of the order being given.
According to the new rule, HHS eliminated the...Read More »
We recently had a case where a patient with severe chronic obstructive pulmonary disease (COPD) was admitted for several lung lesions. The patient went to surgery for de-cortication of lung due to left lung entrapment with adhesions, deep wedge resection of mass of the upper lung and left lower...Read More »
Determining when to code a post-surgical complication as opposed to simply considering it to be an expected outcome after surgery can be a complicated task.
A complication is “a condition that occurred after admission that, because of its presence with a specific principal diagnosis,...Read More »
Our hospital serves a higher than usual population with COPD. Most of these cases are chronic and the patient is typically on home oxygen. Blood gases are almost never obtained on admission unless the patient is placed on a ventilator. Is acceptable to query the physician for chronic respiratory...Read More »
by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS
Too many CDI specialists live for the immediate satisfaction of today. Their primary focus is upon getting a diagnosis documented in the record once and then moving on to the next chart, looking to secure another diagnosis and...Read More »