Q: Are coders required to report a social determinants of health (SDOH) ICD-10-CM code when a CPT code for an evaluation and management (E/M) service level is based on medical decision-making (MDM)?Read More »
Q: What terms need to be included in physician documentation to code in ICD-10-CM whether the patient’s migraine is chronic, intractable, or with status migrainosus?
A: “The patient has a migraine,” is insufficient documentation. Let’s...Read More »
Q: I have a couple of questions regarding CDI metric expectations, reporting, and education for your CDI teams. I have been working on a CDI metrics report of the expected systemwide versus individual query rate, review rate, physician response rate, agreement rate, and expected...Read More »
Q: Are you using contingency staffing in your inpatient programs? If so, do you require any pre-testing to evaluate competency? What has you experience been with using these temporary workers?
Response #1: We currently have more than 10...Read More »
Kerri Swart, BSN, RN, CCRN-K, CCDS, is the CDI director at Upstate University Health System and is associated with the ACDIS Central New York local chapter. She has been in the CDI field for four and a half years.Read More »
Q: What is the pathway for mortality cases at your organization? We review the mortality cases that have a risk of mortality (ROM) and severity of illness score of 4 or below, and to improve the observed to expected ratio (O:E). The workflow, however, is inefficient, and the CDI team...Read More »
Q: I’ve heard some facilities are beginning to incorporate ICD-11, even though it is not yet implemented in the United States. How can coders help their providers transition to ICD-11?Read More »