As part of the sixteenth annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Natalie Negro, MPH, BSN, RN, CCDS, FACHE, corporate CDI manager at Penn Medicine/The Hospital of the...Read More »
Q: How does documentation specificity affect diabetes code assignment?
A: The details included in a medical record can significantly affect code assignments. The following three examples show how documentation specificity, relationships...Read More »
Graft-versus-host disease (GVHD) is an immune-mediated complication that occurs when donor immune cells, specifically T lymphocytes, attack the tissues of the recipient (host). It is most commonly associated with bone marrow and...Read More »
Q: How do you code an encounter with a pregnant patient with diabetes?
A: The prevalence of diabetes in pregnancy has been increasing in our country. Not only is the prevalence of Type 1 or Type 2 diabetes increasing in individuals of...Read More »
Q: When reviewing neurologic cases, what documentation clues, imaging findings, and treatments should coders and CDI specialists look for to identify potential cerebral edema or brain compression diagnoses?
A: Cerebral edema and brain compression are closely related but...Read More »
Q:A patient was initially suspected of having a diagnosis in the history and physical (H&P) that drove the DRG. After review, and without any evidence based supporting clinical indicators noted, the CDI specialist issued a compliant query to clarify...Read More »
