Editor’s Note: AHA Coding Clinic for ICD-9-CM released its second round of ICD-10 coding guidance in its First Quarter 2013 issue. HCPro CDI Education Director Cheryl Ericson, MS, RN, CCDS, CDIP, says the guidance contains information regarding diagnosis clarification,...Read More »
Q:I realize that if the body mass index (BMI) of a patient is documented by nurses and dieticians can be coded if the physician documents the clinical significance (i.e. morbid obesity). However, if the BMI is documented by a patient care tech or nursing ward secretary...Read More »
Have you ever read a history and physical (H&P) report and wondered why the patient was admitted? Have you ever wondered which diagnoses were resolved prior to admission?
If you are a CDI specialist or coder you’ve probably struggled...Read More »
In my senior year of college the physician teaching our pathophysiology class gave the following assignment: “Define acute renal failure (ARF), based on signs, symptoms, lab findings, and cite abnormal laboratory values.”
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 »
The biggest challenge of being a CDI specialist in my opinion is the education of the physicians. They fly by us like stealth bombers and we have limited face-to-face time to make the impression. Fortunately, the snippets of education we do...Read More »
