CDI Journal - Volume 6, Issue 2

The clash of clinical vs. coverage/payment concerns

April 1, 2012
Clinical & Coding, News, Quality & Regulatory

by Trey La Charité, MD

An emergency department (ED) physician diagnosed a patient with pneumonia. He was concerned about a possible nosocomial etiology given the patient’s recent hospital discharge for problems related to atrial fibrillation. Because the patient’s Pneumonia...Read More »
CDI Strategies - Volume 6, Issue 2

Tip: MLN Matters article stresses importance of complete record review

January 19, 2012
Quality & Regulatory

MLN Matters article SE1121 emphasizes that coders must consider all documentation from licensed treating physicians and attending physicians when assigning a principal diagnosis. It states:

“The emergency room report, history and physical (H&P),...Read More »
CDI Journal - Volume 6, Issue 2

Ask ACDIS: Pulmonary hemangioma, VAT/wedge resection as principal

April 1, 2012
Ask ACDIS

What is the correct principal diagnosis in the following case? A 59-year-old male with history of (h/o)bladder cancer and failure to follow up was admitted for video-assisted thoracic surgery (VAT) for  pulmonary nodules found on imaging. The patient had the VAT procedure and a pulmonary wedge...Read More »
CDI Strategies - Volume 6, Issue 2

Q&A: Proper sequencing of heart failure with hypertensive heart/kidney disease

January 19, 2012
Ask ACDIS

Q: I have a question regarding sequencing. I would usually have sequenced 428.21 (heart failure) as principal diagnosis, but I was advised by my inpatient coder that she would sequence 404.91 (Unspecified hypertensive heart and renal disease with heart failure) as the principal...Read More »
CDI Journal - Volume 6, Issue 2

Requirements for diagnostic bronchoscopic procedures

April 1, 2012
Clinical & Coding

by William E. Haik, MD, FCCP

There has been a considerable amount of confusion regarding physician terminology, documentation
requirements, and subsequent coding of various diagnostic bronchoscopic lung procedures. Because the current MS-DRG structure categorizes some of...Read More »
CDI Journal - Volume 6, Issue 2

Dietitian involvement resolves malnutrition query quandary

April 1, 2012
Clinical & Coding, Physician Queries

While most CDI specialists know to query for conditions related to malnutrition, such as obesity and cachexia, programs frequently ignore dietitians’ documentation and keep dietary professionals out of the coding/querying conversation when they should be partners at the table.Read More »
CDI Journal - Volume 6, Issue 2

Expect uncertainty in ICD-10's early days

April 1, 2012
Clinical & Coding

by Lynne Spryszak, RN, CCDS, CPC

The American Hospital Association (AHA) does not plan to “convert” past issues of Coding Clinic for ICD-9-CM into new issues for ICD-10-CM/PCS, the AHA confirmed in a CMS teleconference held in November 2011. This decision caused concern...Read More »
CDI Journal - Volume 6, Issue 2

CDI specialists begin ICD-10 preparation efforts despite discussion of potential implementation delays

April 1, 2012
Clinical & Coding

In October 2010, when ACDIS first conducted its assessment survey regarding CDI readiness for ICD-10 implementation, 83% of respondents indicated they had no formal ICD-10 training and 44% indicated they had no training timeline (www.hcpro.com/...Read More »

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