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 »
When the University of Medicine and Dentistry of New Jersey (UMDNJ) hired Melanie Halpern, RN-BC, MBA, CCDS, CCRA, to implement a clinical documentation and coding integrity (CDCI) program, administration allotted three full-time positions to staff the 550-bed academic medical center....Read More »
It may be too early to start intensive ICD-10-CM training for your coding and CDI team, but now is a good time to at least become familiar with features of the new system.
During CMS’ Basic Introduction to ICD-10-CM National Provider Call held earlier this year, Sue...Read More »
Q: We had a patient come in for back pain and treatment for a possible neurological impingement. However, after a five-day stay, the physician documents neck mass and for the remainder of the stay the resources appear to have been focused on that treatment. How do I discern the principal...Read More »
