Q: I’m in a little debate: Does documentation of the patient’s body mass index (BMI) need to come from an ancillary clinician like the dietitian or nurse? I thought that we could use ancillary documentation for clinical indicators supporting our physician query but that the...Read More »
Q: Over the years I have heard differing opinions regarding whether clinical or coding expertise should be weighed more during the concurrent record review process. I have been told many times to “think like a coder,” and “not get to clinical when you are looking at the chart.”...Read More »
Q: Is it is okay to alter, add to, or take back a query form after the physician answers it?
A: There are two basic situations that support the need for a query. The first and most common situation is when there is evidence of an incomplete, vague, or missing diagnosis...Read More »
ACDIS Associate Editorial Director Linnea Archibald sends out “missed connections” emails with questions from Council members on a regular basis. Anyone with experience related to one of the questions was invited to respond and Archibald connected them with the question-asker. In order to share...Read More »
Q: I am new to the CDI role and looking for suggestions as to how to work with our surgeons to help them beef up their documentation. Do you have any suggestions?Read More »
