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 »
Q: I attended the ACDIS conference in Nashville. (It was excellent!) I had a question about whether or not queries can be used to question the documentation of a condition or procedure where the clinical picture in the record does not appear to support a given diagnosis. I thought the...Read More »
