Q: If documentation states, “probable HIV disease,” is that definitive enough to code?
A: In the instance of HIV, the terms “possible,” “probable,” “likely,” and “suspected” would not apply. Per The Official Guidelines for Coding...Read More »
Q: A question came up recently regarding coding obesity when it is only documented or listed as “a history of obesity.” This seems like it should be a simple concept, but we have heard varying opinions. Some subscribe to the idea that “a history of" could be resolved, so we should...Read More »
Q: I am working on streamlining our templates and would love to include the standard definitions of certain diagnoses, such as malnutrition, to help remind the providers of certain criteria within the body of the template. For instance, I would like to include the Global Leadership...Read More »
Q: We have seen conflicting information on the upper limit temperature threshold for sepsis with some information suggesting greater than 38°C (>38°C) and some stating 38.3...Read More »
Q: Our team had a question regarding the criteria for chronic respiratory failure. The ACDIS Pocket Guide states the criteria “typically requires continuous oxygen support,” so do patients just need to be on continuous oxygen to meet it?
Q: When we open sensitivity reports, there are all sorts of antibiotic resistances with organisms, some cultures have one “resistant” listed while others have multiple. Do you have any guidance as to when we should query for the resistance? If a patient with a positive culture (wound...Read More »
Q: If a provider answers “yes” or “no” to a yes/no query on the actual query template, does the provider also need to document their diagnosis in a note? If the query is part of the permanent medical record, does that answer on the query template suffice and eliminate the need for...Read More »
Question: I am a little confused regarding the meaning “clinically undetermined” or “unable to determine” as a query choice. If a physician chooses unable to determine, does it mean the provider disagrees with the presented choices or disagrees with a diagnosis entirely? For example...Read More »
