Q: Some physicians are uncomfortable making addendums to the discharge summary to include the pathological findings (e.g., malignancy). Instead, they dictate a tumor board note to summarize the course of treatment and final pathological diagnosis. However, the tumor board note is usually dated...Read More »
Q: Confession. I am very frustrated. I am fairly new to CDI. I have a nursing background. I’m trying to understand how the coding and DRG system works. But when I look up a diagnosis in the DRG Expert in the alphabetic index to diseases it is not listed as I would expect it to be....Read More »
Q: How should I query for systemic inflammatory response syndrome (SIRS) if SIRS codes to sepsis? I want to correctly query and obtain the proper supporting information in the medical record in the event of an audit. Any discussion on this topic is appreciated.Read More »
Q: Our small hospital has decided at this time that they no longer need the services of a Physician Advisor (PA). He will only be here another sixty days. Can you tell me from your perspective why a hospital should have a PA?Read More »
Q: Are there any coding guidelines/definitions regarding code 518.5 (Pulmonary insufficiency following trauma and surgery) vs. the use of 518.81 (Acute respiratory failure postop)? If a physician documents postop respiratory failure, which code should we report? I looked in Coding Clinic...Read More »
Q: Our physician provided an illegible diagnosis of malnutrition, and when we queried him regarding the specific type of malnutrition, he provided protein malnutrition. The ICD-9-CMCoding Manual directs us to assign code 260;...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 »
