Determining when to seek clarification regarding patients with altered mental status can be tricky business. Patients who already have established dementia and are now off their baseline with an acute metabolic disorder such as UTI, physicians are typically...Read More »
Q: For some reason, I was under the impression that a query could be answered by any healthcare provider, even one just doing a review of the case (a fellow hospitalist, for instance). I know that a treatment provider is, of course, the way to go but was wondering about this as...Read More »
It started with two courageous coders who knew the query process where they worked at Johns Hopkins Bayview Medical Center, Inc., in Baltimore, wasn't quite right--or compliant.
Specifically, the hospital employed a physician who worked in the billing department to review clinical...Read More »
Q: Recently I have discussed the BMI and malnutrition status on patients with our Registered Dieticians (RD). The question arose as to where our criteria came from. I understand that the...Read More »
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 »
