Q:Since Acute Renal Failure (ARF) is no longer a MCC (as of October 1, 2010). I would like some input on how facilities have coped with the change. Do you just code ARF, or have you started querying physicians for more specific information such as documentation for...Read More »
Although AHIMA’s October 2008 practice brief “Managing an Effective Query Process” clearly states that the agency intended the article as guidance, not regulation, CDI programs should regularly review their query practices, policies, and procedures to determine if any problem areas may need to...Read More »
Like many CDI specialists, Janice Davis, RN, clinical documentation analyst at High Point (NC) Regional Health System and her four co-workers struggled with obtaining appropriate documentation for chronic kidney disease (CKD) and acute renal failure (ARF). “So we decided if we listed the...Read More »
The concept of standard operating procedures (SOP) might easily call to mind assembly lines or retail-related employee handbooks. But CDI programs should establish such basic operating policies to clarify expectations for CDI staff and the healthcare professionals who interact with them....Read More »
CDI specialists are charged with reviewing concurrent medical records on the hospital floor and clarifying clinical documentation when appropriate. I emphasis the term “appropriate”because there hardly seems to be a time when the opportunity for a clinical query does not exist....Read More »
Hypothetical question: You don’t know how to swim, but you’re learning. You have an inner tube around your waist. Now, where would you rather continue your lessons–in the pool in your backyard or in the ocean?
A friend of mine posed this question to me...Read More »
Only 1.5% of the nearly 3,000 nonfederal hospitals in the United States reported the use of a comprehensive electronic medical record (EMR) system, according to a March report published in the New England Journal of Medicine. With so few facilities employing EMRs, why should CDI program managers...Read More »
The reason for assignment of a certain principal diagnosis is occasionally incomprehensible. First, consider what a principal diagnosis is. It’s the condition or group of conditions that, after workup, the physician determines led to the patient requiring...Read More »