Editor’s Note: Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, MCP, presents “Integrating CDI processes with the EHR: Getting it right from the beginning,” on Tuesday, May 22 at 3:15 p.m., in Track 7, Leadership and Department Management. The follow Q&A was conducted by ACDIS Member...Read More »
Q:Could you please explain unrelated surgical procedure DRGs? For example, a patient with a principal diagnosis of pneumonia whose surgical procedure transurethral resection of the prostate (TURP), MS-DRG 168. Also can you explain how we can differentiate between...Read More »
Q: I realize that if the body mass index (BMI) of a patient is documented by nurses and dieticians, it can be coded if the physician documents the clinical significance (i.e., morbid obesity). However, if the BMI is documented by a patient care tech or nursing ward secretary in...Read More »
Q: The physician documented mild bronchitis treated with Zithromax in the progress note on day two of the patient’s hospital. I looked for clinical indicators and the only documentation I found in the nursing notes was that the patient had a non-productive cough on admission. ...Read More »
Q: Is it true that a CDI physician advisor/champion cannot be a direct patient care provider?
A: CDI departments are not required to have a physician advisor; however, it is beneficial to have a physician champion. I make a distinction between the two...Read More »
