Many cases exist in which CDI specialists need to query physicians to clarify the use of the term “history.” Consider the following situation in which a physician admits a patient with pyelonephritis. The past history states right lower lobe lung carcinoma proximal lesion. ...Read More »
I previously started a conversation on CDI Talk entitled “Failed Programs,” hoping there might be someone willing to divulge an account of how and why their program “failed,” perhaps even how they were able to “save” or “reinvent” it. While the post generated quite a bit of conversation (there...Read More »
Q:I have been trying to determine whether a skin graft includes debridement. Based on what I have read in the Official Guidelines for Coding and Reporting and ...Read More »
by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS
Because most CMS local and national coverage determinations governing medical necessity and limitations of coverage center around outpatient procedures (e.g., lesion removals, cataract surgeries, and blepharoplasty repairs),...Read More »
In 2002 the National Quality Forum (NQF) created its report Serious Reportable Events in Healthcare. The report identified 27 adverse events that should never occur in hospitals. In 2006, the NQF added one item to the list.
Now, the agency has ratified an updated list of 29...Read More »
J.A. Thomas and Associates (JATA) says nearly a quarter of healthcare facilities are not “currently taking steps toward ICD-10 transition” according to survey results released earlier this month. The survey garnered...Read More »
While the bulk of discussion regarding how to ethically and responsibly submit queries to physicians revolves around releases from the American Health Information Management Association (AHIMA) releases, don’t discount advice from other potential sources. For example,...Read More »
