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 »
CDI specialists should know what to look for when reviewing cancer admissions in order to capture the true severity of these patients’ illnesses. Often patients are discharged with the diagnosis of “possible” or “probable” cancer when the pathology report is...Read More »
This is a classic documentation opportunity to clarify “volume/fluid overload,” says Lynne Spryszak, RN, CPC-A, CCDS, CDI education director for HCPro, Inc., in Danvers, MA. “If the physician hasn’t documented acute CHF, I would hesitate to ask for this condition based on this mild BNP elevation...Read More »
