“If you’ve ever read a document that contained convoluted language or gibberish jargon, read on,” a press release from The Center for Plain Language stated. I received that release more than a...Read More »
by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS
While riding the gondola at Snowbasin ski area last week in Utah, I had the opportunity to converse with a physician (who happened to be riding up the lift with me) regarding the field of CDI. His interpretation of CDI centered...Read More »
Q:I am looking for help posing queries regarding the specific link between diabetes and conditions typically considered diabetic complications. Should we always query the physician regarding the link between the presenting symptom and the diabetes?
We, in the United States, will soon need to adopt the electronic health record (EHR). Over the past few years, of course, healthcare entities have slowly converted from the traditional handwritten medical record toward one that is totally digital. There have...Read More »
Q:I know that in an inpatient setting coders are allowed to use a suspected diagnosis when a definitive diagnosis cannot be determined. However, we have had some trouble with physicians using the term “rule out” or “differential diagnosis” when it comes to a recovery...Read More »
I challenge you to find one textbook of medicine, physiology, or pathology that refers to a category of hematologic abnormality as “acute blood loss anemia.”
But coders are very familiar with that term. They may ask a physician whether a...Read More »
Q:Since Acute Renal Failure (ARF) is no longer a MCC (as of October 1, 2010). I would like some input on how facilities have coped with the change. Do you just code ARF, or have you started querying physicians for more specific information such as documentation for...Read More »
Q: I have been dealing with a denial issue where, because a chest x-ray did not show pneumonia and a repeat x-ray was not performed, the pneumonia was denied. In dehydrated or immunocompromised patient the chest x-ray may not initially show the pneumonia. I am now looking for supporting...Read More »
