CDI Journal - Volume 9, Issue 5

Ask ACDIS: Non-treating physician responses to queries

September 1, 2015
Ask ACDIS

Q: May a physician/provider, who does not attend the patient during an episode of care but does act in an advisory capacity for the CDI and/or coding departments, answer a formal query? Could that documented response be used as a basis for compliant code assignment?Read More »
CDI Strategies - Volume 9, Issue 5

News: OIG sites two San Antonio facilities for Kwashiorkor errors

March 5, 2015
News, Quality & Regulatory

For calendar years (CYs) 2010 and 2011, Medicare paid hospitals $711 million for claims that included a diagnosis code for Kwashiorkor, a form of severe protein malnutrition typically found in third-world countries that is extremely rare in the United States.Read More »
CDI Journal - Volume 9, Issue 5

In the News: CCDS certification set to receive an ICD-10 update

September 1, 2015
News

There are a lot of changes coming with ICD-10—including an update to the exam for the Certified Clinical Documentation Specialist (CCDS) credential. Beginning in mid-January 2016, the exam will include ICD-10-related questions.Read More »
CDI Journal - Volume 9, Issue 5

Meet a member: Foreign Medical Grad finds CDI home in California

September 1, 2015
Education

Romerl “Cris” Gumayagay, CCDS, CCS, CDIP, knows a thing or two about having passion for CDI. The foreign medical graduate (FMG) has been involved in CDI for more than five years and holds a CDI position at the University of Southern California, Keck Medicine, in Los Angeles.Read More »
CDI Journal - Volume 9, Issue 5

Ask ACDIS: Escalation policies and clinical validation queries

September 1, 2015
Ask ACDIS

Q: What are other facilities doing to avoid denials on the back end and code the chart accurately the first time with a clinically supported diagnosis?

A: You bring up an excellent point. If the clinical indicators do not seem to support the diagnosis, it is the responsibility of the CDI/...Read More »
CDI Strategies - Volume 9, Issue 5

Q&A: What are the rules for using information from ambulance forms or trip tickets?

March 5, 2015
Ask ACDIS

Q: Can CDI programs use information on ambulance forms or trip tickets to abstract from if the information is pulled into or reiterated in the ED or history and physical (H&P) documentation? Our staff doesn’t want to miss criteria that would diminish our ability to substantiate the...Read More »
CDI Journal - Volume 9, Issue 5

Clinically Speaking: Adding venous thromboembolism to the CDI checklist

September 1, 2015
Clinical & Coding

by Linda Renee Brown, RN, MA, CCDS, CCS, CDIP

The annual incidence of an initial venous thromboembolism (VTE) event, either a pulmonary embolus (PE) or a deep vein thrombosis (DVT), is approximately 0.1% in the United States, with the highest incidence among the elderly and a...Read More »
CDI Journal - Volume 9, Issue 5

Coding Clinic for CDI: Defining root operations

September 1, 2015
Clinical & Coding

by Sharme Brodie, RN, CCDS

Many of the questions and answers supplied in AHA Coding Clinic for ICD-10-CM/PCS, Second Quarter
2015, surrounded the use of the correct root operation. Per ICD-10-PCS Official Guideline for Coding and
Reporting, “[i]t is the coder...Read More »

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