By Anny Yuen, RHIA, CCS, CCDS, CDIP, and Page Knauss, BSN, RN, LNC, ACM, CPC, CDEO
In many instances, the documentation for a particular service needs to be provided before the encounter. This is especially true for diagnostic tests such as MRI scans.Read More »
By Howard Rodenberg, MD, MPH, CCDSDo you ever wonder if your professional skills are actually useful in the real world? I know I do. My resume as an emergency physician falls apart when applied outside of the ED, where it turns out you’re not allowed to stare at someone writhing on the...Read More »
Many organizations have HCC tools built into their CDI software or EHRs that can help them capture HCCs. When providers click on a diagnosis or a condition, the tool will mark whether the diagnosis is an HCC. Other technology can extract pharmacy data, lab data, other diagnoses, and the problem...Read More »
Even if the treating physician does not immediately document “acute respiratory failure” in the pediatric patient’s record, looking for specific wording and indicators can help support a CDI query to bring that diagnosis in—provided it is appropriate for that patient during that encounter.Read More »
By Anny Yuen, RHIA, CCS, CCDS, CDIP, and Page Knauss, BSN, RN, LNC, ACM, CPC, CDEO
The terms “inpatient” and “outpatient” can refer to the clinical setting, but they also indicate the types of procedures performed. Inpatient procedures require that the patient be admitted to the...Read More »
Recently, I was asked an interesting question about querying for the diagnosis of encephalopathy. The student asked whether it was required for a patient to return to their mental status baseline prior to the CDI specialist querying the...Read More »
By Howard Rodenberg, MD, MPH, CCDS
When my son was in middle school, I would call him every evening to review the school day. I would want to know all about the things he was learning and the friends he was making, and he would grudgingly oblique me with a one-word answer if he...Read More »