May a physician/provider, who does not take care of a patient during an episode of care answer a query for another physician who did take care of the patient, but does not have time to answer the queries issued to them by the CDI/coders? Could that documented response be used as a basis for...Read More »
As part of the eleventh annual Clinical Documentation Integrity Week, ACDIS conducted a series of interiews with CDI professionals on a variety of emerging industry topics. Keisha Downes, BSN, RN, CCDS, director of CDI at Wellforce in Boston, Massachusetts, answered these questions.
ACDIS celebrates CDI specialists annually with a full week of recognition for the profession through activities, education, and fun. This year’s CDI Week theme is CDI Kitchen: Recipes for a Successful Program, aiming to go back to the basics of what it takes to make a CDI program great...Read More »
The False Claims Act of 1863 imposes penalties on anyone who submits a “false claim” for services that were not actually performed. In healthcare, that means CMS needs to check that all services billed are clinically valid and the patient...Read More »
My physicians use the term “bacteremia” frequently and are treating it. The patient may be febrile and receiving antibiotics, but they cannot figure out a source. What should they be calling it? Or, better yet, what query should I be sending?Read More »
We’re having a lot of discussions lately on whether we should query for pressure injuries when they’re only documented by nursing. Our wound care nurses determined that staff nurses identify pressure injuries correctly only 60% of the time. If we’re querying based on nursing documentation, our...Read More »
What are the requirements when it comes to a physician advisor asking for diagnoses to be added to the medical record? Based on the ACDIS/AHIMA “Guidelines for achieving a compliant query practice” brief, physician advisors follow the same requirement of a CDI specialist with a compliant...Read More »
Our query process currently creates a physician progress note when a query is answered which becomes part of the permanent medical record. We do keep the original query as well, which clearly identifies the query author and it is discoverable, but not as part of the medical record. We included...Read More »
