Q:When atelectasis is noted on an ancillary test such as a CT-scan of the abdomen or chest x-ray can nursing documentation of turning, coughing, and deep breathing considered an intervention that qualifies as one of the criteria to meet a secondary diagnosis?...Read More »
Coders and clinicians seem to speak different languages. CDI specialists often serve as the translators between clinicians and coders, so it's important that all three groups work together.
Both coders and CDI specialists can query physicians when documentation:
by Wendy Whittington, MD, MMM
Physicians are grappling with understanding what all of the changes in healthcare mean for their patients and themselves, and CDI efforts are part of that equation.
I am privileged to be part of the faculty group that teaches physicians in the...Read More »
by Glenn Krauss, BBA, RHIA, CCS,CCS-P, CPUR, FCS, PCS, C-CDIS, CCDS The No. 1 struggle most CDI specialists face is getting physicians engaged in CDI, to provide accurate, specific, consistent documentation in the record. Unfortunately, unless healthcare is reformed to the point...Read More »
Q: An intoxicated patient comes into the emergency department with a history of alcoholism and the physician prescribes precautions for withdrawal and documents “tremors.” Can we assume that the physician means “delerium tremors” or “DTs”?
Q: I’ve been confused recently regarding coding from the pathology or radiology reports for specificity. It seems that in recent years, (I’ve been coding for 25years) a new interpretation of the coding guidelines has come about. I was taught that as long as a physician with direct...Read More »
We all have those tough days to be sure. Some days are tougher than others. But when a physician writes, “Duh! It’s a no brainer!” in response to a query you’ve just asked, it can be a little tough to take. Thankfully, CDI professionals have a committed network of their peers by way of the ...Read More »
Consider these steps when approaching the oftentimes daunting task of revising queries:
Step one: Inventory all queries. “You may find that some [queries] are no longer relevant, or some are so poorly written that you wouldn’t want to be using them in the first place,”...Read More »
