Physician advisors serve a variety of purposes beyond documentation improvement, including assisting case management, utilization review, quality, and coding departments, among other assignments, according to a recent benchmarking report and survey from ACDIS.Read More »
Q:If a patient is extubated post-operatively but continues to be treated with supplemental oxygen, when is a query for acute respiratory failure appropriate?
A: To determine if this represents acute respiratory failure, the values for...Read More »
It’s been four years since ACDIS asked its members to offer up their thoughts about the role of the physician advisor in clinical documentation improvement efforts. In those four years, much in the CDI world has changed but one thing hasn’t—CDI programs still say the role of the physician...Read More »
Some clinicians may interpret a query as an affront to their clinical judgment. This is not your intent. You are trying to determine whether a condition was present and whether it should compliantly be coded or not.
It’s a glass half-full kind of result—40% of “ACDIS Radio” listeners (of the October 28, 2015, broadcast) say their CDI program has an established query auditing process in place. But there’s definitely room to add more milk to the glass: Another 29% say they have some query review practices...Read More »
Each facility should have a specific plan in place between CDI and coding for how to handle unspecified diagnoses, says Katy Good, RN, BSN, CCDS, CCS, CDI coordinator at Flagstaff Medical Center in Arizona. Her facility opted to focus primarily on two things when it came to ICD-...Read More »
Q: I have a question about the following query. If the response is B, can you still capture it as withdrawal?
Based on these indicators taken from the medical record, please clarify by documenting on this query form and/or in the progress note the condition...Read More »
