by Richard Pinson, MD, FACP, CCS and Cynthia Tang, RHIA, CCS
The clinical world now has a new set of criteria for malnutrition, thanks to representatives from the American Society for Parenteral and Enteral Nutrition (ASPEN), the European Society for Clinical Nutrition and...Read More »
Q: Our coders often select the principal diagnosis based on how invasive the testing is. For example, a patient comes in with vertigo and hematemesis. For the vertigo, the physician orders a brain CT, IV medications, and an ear, nose, and throat consult. The patient is diagnosed...Read More »
by Cesar M. Limjoco, MD
Sepsis has been defined as a toxic response to infection. Sepsis-1 and Sepsis-2 defined it as a systemic inflammatory response to infection. Sepsis-3 now defines it as life-threatening organ dysfunction caused by a dysregulated host response to infection....Read More »
Rules governing code assignment often don’t make sense to those coming to CDI from the clinical side of the house. In truth, they often confound professionals with years of HIM/coding experience, too. And most CDI and coding professionals have a list of frustrations when it comes to translating...Read More »
by Sharme Brodie, RN, CCDS
I’m glad I’m not the only one who sometimes has a problem determining the proper codes and their proper sequence. I also must not be the only person out there who has questions about coding diabetes, it turns out, because the Third Quarter 2018 edition...Read More »
Q:If the patient comes in with a high blood alcohol level and the provider documents that number in their note, do they also need to specifically write “patient with intoxication?”Read More »