Q:The majority of the admissions I am reviewing this week are for an elderly population. It seems that they all have the same admitting diagnoses: Failure to thrive (FTT), urinary tract infection (UTI), fever, dehydration, altered mental status (AMS). I am confused...Read More »
It’s been more than two weeks since ICD-10 became the official code set and the sky hasn’t fallen. Despite claims that from the AMA and other physician groups that ICD-10 was a “looming disaster” that...Read More »
In 2004, the Coordination and Maintenance Committee created a definition of sepsis that became the basis of ICD-9-CM’s Official Guidelines for Coding and Reporting and was used in a number of AHA’s Coding Clinics. That definition included...Read More »
Q: Our physicians frequently document ‘meets sepsis criteria.’ Is this a bad habit forming? If the patient is septic, shouldn’t the physician state sepsis due to, or just sepsis? I worry that if the patient has a few vital signs off the physicians are documenting sepsis...Read More »
Six years ago I left a position as the director of education at a large hospital and took on the role of CDI specialist. I was not sure what the role entailed or how I was going do it but knew that with more than 20 years in nursing I had the...Read More »
Q: I attended the ACDIS conference in Nashville. (It was excellent!) I had a question about whether or not queries can be used to question the documentation of a condition or procedure where the clinical picture in the record does not appear to support a given diagnosis. I thought the...Read More »
Q:I have come across an ethical dilemma. We have a small CDI program and a “home grown” application we use to report metrics to the chief financial officer (CFO). In this, we track whether a CDI specialist’s query captured a CC/MCC. If it is the first and/or only CC/MCC...Read More »
