Many cases exist in which CDI specialists need to query physicians to clarify the use of the term “history.” Consider the following situation in which a physician admits a patient with pyelonephritis. The past history states right lower lobe lung carcinoma proximal lesion. ...Read More »
While the bulk of discussion regarding how to ethically and responsibly submit queries to physicians revolves around releases from the American Health Information Management Association (AHIMA) releases, don’t discount advice from other potential sources. For example,...Read More »
Q: I am wondering about whether coders can use information the physician takes from test results and includes in the history and physical (H&P). We recently had a situation where the H&P indicated under the studies section that “chest x-ray showed atelectasis,” or “EKG showed...Read More »
This month’s question was submitted on June 30, 2023, and focuses on compliant queries. Please note that questions and answers have been de-identified for the purposes of this article.
Q: Our issue is that when constructing the query, the CDI specialist/coder is giving...Read More »
Can you begin to imagine how complex a piece of great literature would be in we had to include complete documentation of each medical incident? Or have to stop every time we have to develop physician queries?
Let’s take a look at the classic tale Gone...Read More »
If you have experience with the topics below, please email Linnea Archibald at larchibald@acdis.org by noon eastern on Friday, June 16, and she'll connect you with the relevant folks at the end of the day on...Read More »
If you have experience with the topics, please email Associate Editorial Director Linnea Archibald at larchibald@acdis.org by noon eastern on Friday, April 14, and she'll connect you with the relevant folks...Read More »
Q: Are there any coding guidelines/definitions regarding code 518.5 (Pulmonary insufficiency following trauma and surgery) vs. the use of 518.81 (Acute respiratory failure postop)? If a physician documents postop respiratory failure, which code should we report? I looked in Coding Clinic...Read More »
