While most CDI specialists know to query for conditions related to malnutrition, such as obesity and cachexia, programs frequently ignore dietitians’ documentation and keep dietary professionals out of the coding/querying conversation when they should be partners at the table.Read More »
Q: Is it okay to include a definition of “functional quadriplegia” when we query the physician for this condition? I was surprised when I approached a physician to discuss this diagnosis and he had not heard of it. However, when I gave him the definition, he agreed with it and...Read More »
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 »
