Q: I understand the Official Guidelines for Coding and Reporting related to pressure injuries and present on admission (POA) status. For example, I know that if a decubitus ulcer is a stage 1 on admission and progresses to stage 4 during the stay, we are to code stage 1...Read More »
By Lynelle A. Clausen, RN, BSN
I started working as a CDI specialist in May 2014, and was assigned to oncology, intensive care and the step–down unit (SDU) to complete reviews. I have a seasoned clinical background in these areas and knew what to look for in the medical record....Read More »
The necessity for submitting a query to the provider for the specificity of heart failure seems to remain one of the leading reasons to query year after year, despite the efforts of CDI specialists to provide robust education around...Read More »
While the ACDIS offices are closed for the Thanksgiving holiday until Monday, November 26, the ACDIS team wanted to spread some holiday cheer with some “helpful” Thanksgiving coding tips.Read More »
It’s often a challenge for CDI specialists to obtain precise documentation of anemia in the medical record. A hospitalist once asked me why I sent him a query for anemia because since he would treat it the same way no matter what, he...Read More »
