By Marion Kruse, BSN, RN, MBA, and Jennifer Cavagnac, CCDS
The decision of when to query the physician represents an important aspect of the CDI program. In a perfect world, all cases would be reviewed within the first 24 hours of admission. However, due to staffing...Read More »
I think we’re all familiar with the Law of Unintended Consequences. That’s the concept that something begun with the best of intentions can wind up going horribly awry. Examples include “New Coke” and anything ending in the word “Kardashian.” (...Read More »
Although managing accurate principal diagnoses and CC/MCC assignment is always going to be a focus for CDI professionals and coders (along with clarifying general documentation inconsistencies). Clinical validation denials are on the rise, making record...Read More »
Q: During a final pre-bill coding review, the coding leader identifies a CDI initiated query that does not meet the ACDIS/AHIMA guidelines for a compliant query. But, the physician has already responded to the query with a diagnosis which was then...Read More »
By Howard Rodenberg, MD, MPH, CCDSDo you ever wonder if your professional skills are actually useful in the real world? I know I do. My resume as an emergency physician falls apart when applied outside of the ED, where it turns out you’re not allowed to stare at someone writhing on the...Read More »
By Howard Rodenberg, MD, MPH, CCDS
When my son was in middle school, I would call him every evening to review the school day. I would want to know all about the things he was learning and the friends he was making, and he would grudgingly oblique me with a one-word answer if he...Read More »
Q: Is it appropriate to query whether a pressure ulcer was present on admission (POA) if it was not documented until later in the admission?Read More »
Q:Our coders are having trouble determining how much clinical evidence to cite in our queries. Is there a general rule for how much to include?Read More »
