Q:A patient was initially suspected of having a diagnosis in the history and physical (H&P) that drove the DRG. After review, and without any evidence based supporting clinical indicators noted, the CDI specialist issued a compliant query to clarify...Read More »
Q: A CDI specialist asked me if they could put a photo in a query. I’m used to noting in the query where in the chart the provider can find the photo, but I have never actually put a photo in the query itself. Is this allowed?
Q: If a provider answers a query and the response requires further clarification, is it compliant to contact the provider by phone or other outside query method, have a conversation with the provider, and then ask/encourage them to add to their note without documentation regarding...Read More »
A very happy New Year from the ACDIS team! Now that we’re done with celebrations and counting down the seconds until midnight, it’s time to reengage and kick off 2026 with only the best of what our publications have to offer. Since provider engagement remains one...Read More »
Q: Do your query templates ever include the clinical criteria needed to establish the diagnosis being queried when multiple choice diagnoses are offered? For example, on a sepsis query, does the query itself include the institutional criteria for establishing the diagnosis or is this...Read More »
Q: I have a situation where providers are using abbreviations such as AHRF for acute hypoxic respiratory failure, ADHF for acute decompensated heart failure, etc. Can I code these conditions, or do I need to query to clarify the abbreviation? Read More »
