Q: I recently was reviewing a chart where the infection control physician stated the patient had sepsis, but the attending listed bacteremia as the diagnosis. I sent a query to clarify which was correct and the attending confirmed bacteremia. On the...Read More »
By Lori Drodge, RHIT, CCS
Ever find yourself thinking that you have too much work to do to find time to read and digest a recent publication of AHA’s Coding Clinic? If so, your hospital’s severity adjusted data could be suffering. All conditions that meet reportable...Read More »
Q: What do you suggest the providers write to describe medication/substance overdose? In my experience, physicians don’t write “poisoning” in these cases. Read More »
My colleague Dr. Douglas Campbell, my senior partner and mentor in all things CDI, dropped into my glass-fronted office the other day with a question. I mention the glass because, as, Dr. Campbell had the foresight to have his glass wall frosted...Read More »
Q: I’ve heard that if a condition cannot be identified as POA, it will not keep the criteria for a principal diagnosis and cannot be sequenced as such. I recently had a patient who was admitted for syncope and all the workup was negative, but it’s...Read More »
I was recently reviewing Coding Clinic, First Quarter 2018, and felt that the question regarding physeal fractures needed more clarification and explanation than was provided in the official answer.
Q: We recently had a situation where a patient was admitted for syncope workup and all the workups were negative except for incidental findings of AKI. The physician documented “AKI likely 2/2 hypovolemia. Treatment focus is to trend creatinine levels...Read More »
by Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS
Coding reviews provide an opportunity for you to conduct a thorough compliance review that not only addresses other components of the coding process but also the integrity of the patient’s record.Read More »