Q: We are looking for ways to have our CDI and utilization management (UM)/utilization review (UR) teams work more closely and possibly cross-train the team members. Does anyone currently work closely with the utilization management department or have cross-trained employees? Does...Read More »
Q: If a physician performs a lithotripsy on a stone in the ureter or removes a stone from the ureter through a transurethral approach, then performs a percutaneous nephrostomy and treats a stone in the kidney, would both procedures be reported?
Q: Would anyone be willing to share how their CDI departments are reviewing for sepsis? A while back, my hospital administration went to contracts and requested that I follow up with physicians and staff and start reviewing all commercial insurance and managed Medicare accounts with...Read More »
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 »
