CDI Blog - Volume 5, Issue 43

Q&A: Syncope due to UTI

November 21, 2012
Ask ACDIS, Clinical & Coding

Q: A patient with a long history of Type I diabetes is admitted after a syncopal episode. Urine culture grows greater than 100,000 E. coli, and the physician documents a diagnosis of urinary tract infection (UTI) treated with PO Bactrim. If the physician documents the...Read More »
CDI Blog - Volume 5, Issue 42

Q&A: Determining what constitutes a leading query

November 14, 2012
Ask ACDIS, Physician Queries

Q: What are the ramifications of leading queries? Who is monitoring whether a query is leading?...Read More »
CDI Strategies - Volume 5, Issue 27

Q&A: ’Suggestive’ documentation could require clarification

December 22, 2011
Ask ACDIS

Q:Does documentation such as “suggestive of” or “suspicious of” qualify as uncertain...Read More »
CDI Strategies - Volume 5, Issue 25

Q&A: Making present-on-admission queries part of the record

December 1, 2011
Ask ACDIS

Q:Should present-on-admission (POA) queries stay in the record and become a part of the...Read More »
CDI Strategies - Volume 5, Issue 24

Q&A: Post-surgical complication of encephalopathy

November 10, 2011
Ask ACDIS

Can a patient have encephalopathy after a surgery? For example, a patient post surgery becomes confused and ends up being transferred from the medical/surgical floor to the ICU and began receiving high doses of pain medication via IV. However, the patient recovers well and the confusion...Read More »
CDI Strategies - Volume 5, Issue 23

Q&A: Resection or excision in ICD-10

October 27, 2011
Ask ACDIS

Q:I am unsure how “ribs” are categorized in ICD-10. I don’t understand if taking one rib is considered a...Read More »
CDI Blog - Volume 5, Issue 22

Q&A: Driving the bus for DRG assignment

May 30, 2012
Ask ACDIS, Clinical & Coding

Q: If the principle diagnosis ICD-9 code is on the MCC list but there is no other diagnosis for the patient, is the DRG assigned with MCC or without?

For example, patient presents with heart failure but has no other diagnoses. So the ICD-9 code is 428.21, acute...Read More »
CDI Strategies - Volume 5, Issue 22

Q&A: Using tumor board notes post discharge

October 13, 2011
Ask ACDIS

Q:  Some physicians are uncomfortable making addendums to the discharge summary to include the pathological findings (e.g...Read More »

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