Q: I’ve been confused recently regarding coding from the pathology or radiology reports for specificity. It seems that in recent years, (I’ve been coding for 25years) a new interpretation of the coding guidelines has come about. I was taught that as long as a physician with direct...Read More »
We all have those tough days to be sure. Some days are tougher than others. But when a physician writes, “Duh! It’s a no brainer!” in response to a query you’ve just asked, it can be a little tough to take. Thankfully, CDI professionals have a committed network of their peers by way of the ...Read More »
Connolly Healthcare, the Recovery Auditor (RA) for Region C, continues to focus on complex inpatient reviews of a long list of MS-DRGs. Regardless of whether this is your hospital’s RA, you need to ensure that your records reflect the...Read More »
Consider these steps when approaching the oftentimes daunting task of revising queries:
Step one: Inventory all queries. “You may find that some [queries] are no longer relevant, or some are so poorly written that you wouldn’t want to be using them in the first place,”...Read More »
Q:The majority of the admissions I am reviewing this week are for an elderly population. It seems that they all have the same admitting diagnoses: Failure to thrive (FTT), urinary tract infection (UTI), fever, dehydration, altered mental status (AMS). I am confused...Read More »
It’s been more than two weeks since ICD-10 became the official code set and the sky hasn’t fallen. Despite claims that from the AMA and other physician groups that ICD-10 was a “looming disaster” that...Read More »
In 2004, the Coordination and Maintenance Committee created a definition of sepsis that became the basis of ICD-9-CM’s Official Guidelines for Coding and Reporting and was used in a number of AHA’s Coding Clinics. That definition included...Read More »
Q: Our physicians frequently document ‘meets sepsis criteria.’ Is this a bad habit forming? If the patient is septic, shouldn’t the physician state sepsis due to, or just sepsis? I worry that if the patient has a few vital signs off the physicians are documenting sepsis...Read More »
