The concept of standard operating procedures (SOP) might easily call to mind assembly lines or retail-related employee handbooks. But CDI programs should establish such basic operating policies to clarify expectations for CDI staff and the healthcare professionals who interact with them....Read More »
CDI specialists are charged with reviewing concurrent medical records on the hospital floor and clarifying clinical documentation when appropriate. I emphasis the term “appropriate”because there hardly seems to be a time when the opportunity for a clinical query does not exist....Read More »
Q: Do you code the procedure for tissue plasminogen activator (tPA) administration when it is done in your emergency room for patients being admitted with cerebrovascular accident (CVA)/stroke on inpatient cases?
I believe the procedure code is 99.10...Read More »
Those who lived through the RAC demonstration project learned valuable lessons along the way, lessons that CDI professionals can use as the RAC reviews become permanent and audits begin to take on more medical necessity and documentation concerns.
Known primarily as a medical transcription and documentation firm, Tennessee-based Spheris was nevertheless the nation’s second-largest provider of clinical documentation technology and services. Earlier this month, the company filed for bankruptcy, according to an article in the ...Read More »
Within the Alphabetic Index of ICD-9-CM is a Neoplasm table that assists coders in assigning diagnosis codes (Vols. 1-2). The table is structured based off the specific location of the neoplasm as well as the type of neoplasm. There are four types of neoplasms on the neoplasm table:...Read More »
Every so often, I come across some coding issues that recall other coding issues. I found this situation within the last few weeks and it deserves some discussion.
A baby arrives at the hospital with weight loss....Read More »
ACDIS members who frequently use the CDI Talk message board already appreciate the hard work and generosity of Sandy Beatty, RN, BSN, C-CDI, clinical documentation specialist at...Read More »
