Q: Is systemic inflammatory response syndrome (SIRS) an inherent part of an infection? For example, when a patient comes in with pneumonia, and clinical indicators are present for SIRS but the physician did not specifically write SIRS, should coders or CDI specialists query physicians?...Read More »
As facilities vie for government incentives to implement electronic health record systems they may find CDI programs provide a hidden benefit.
The biggest challenge related to meeting governmental standards for “meaningful use” of EHR “is that they require physician documentation and...Read More »
Confusing coding guidelines and insufficient documentation have made neoplasms a target area as HealthDataInsights—the RAC for Region D—recently said it will take a closer look at MS-DRGs 837–948.
“…[T]here are opportunities for error within this subset of MS-DRGs,” says Paul Evans,...Read More »
CMS requires that orders for healthcare services be authenticated using either a handwritten or electronic signature. CMS has made it clear that stamped signatures are not an acceptable form of authentication and previous language in the CMS Program Integrity Manual required a “legible...Read More »
Q: If a CDI specialist or coder queries a physician and the response is written on the query letter is it legal to code from this? Or should the physician only respond in his or her progress note or discharge summary? Also, can the facility...Read More »
Q:A patient is admitted with an elective colon resection. The physician documents postoperative ileus but then on the day of discharge the notes states: expected postoperative ileus. So do we add the code 997.4 or not?
We are currently seeking speakers to present at the 2011 ACDIS Fourth Annual Conference, to be held April 7-8, 2011 at the Hilton Walt Disney Resort in Orlando.
Speakers willing to present on all aspects of clinical documentation are welcome and we encourage new and unique ideas. Case...Read More »
The Centers for Medicare & Medicaid Services (CMS) recently approved the first “medical necessity review” audits for the recovery audit contractor (RAC) program,...Read More »
