CDI Strategies - Volume 4, Issue 20

Q&A: Obtaining documentation for multiple significant trauma

September 30, 2010
Ask ACDIS

Q: Whenever we get a trauma patient, it’s either very easy to get to the multiple significant trauma (MST) major diagnostic category (MDC), or it becomes a real challenge, especially taking into account the rules pertaining to two body sites...Read More »
CDI Strategies - Volume 4, Issue 19

Q&A: Michigan ACDIS chapter offers opinions on verbal orders in CDI

September 16, 2010
Ask ACDIS

Q: Our CDI specialists call the physicians when queries have not been answered. Sometimes the physician will give us an answer over the phone. I’m wondering if that’s okay. Can our CDI staff, who are registered nurses, take the verbal...Read More »
CDI Blog - Volume 4, Issue 18

Q&A: Querying for SIRS when clinical indicators are present

March 31, 2011
Ask ACDIS, Clinical & Coding

Q: Is systemic inflammatory response syndrome (SIRS) an inherent part of an infection? For example, when a patient comes in with pneumonia, and clinical indicators are present for SIRS but the physician did not specifically write SIRS, should coders or CDI specialists query physicians?...Read More »
CDI Strategies - Volume 4, Issue 18

Q&A: Facility policies should dictate whether queries are part of the medical record

September 2, 2010
Ask ACDIS

Q: If a CDI specialist or coder queries a physician and the response is written on the query letter is it legal to code from this? Or should the physician only respond in his or her progress note or discharge summary? Also, can the facility...Read More »
CDI Blog - Volume 4, Issue 17

Q&A: Resolving coding postoperative ileus worries with documentation

March 23, 2011
Ask ACDIS, Clinical & Coding

Q: A patient is admitted with an elective colon resection. The physician documents postoperative ileus but then on the day of discharge the notes states: expected postoperative ileus. So do we add the code 997.4 or not?

A: ICD-9-...Read More »
CDI Strategies - Volume 4, Issue 17

Q&A: Don't discharge the discharge summary

August 19, 2010
Ask ACDIS

Q: Should coders wait for the discharge summary before coding?

A: The answer is complicated because coders generally are held accountable to both the compliance and finance...Read More »
CDI Blog - Volume 4, Issue 16

Q&A: Searching for the principal diagnosis

March 16, 2011
Ask ACDIS, Clinical & Coding

Q: We had a patient come in for back pain and treatment for a possible neurological impingement. However, after a five-day stay, the physician documents neck mass and for the remainder of the stay the resources appear to have been focused on that treatment. How do I discern the principal...Read More »
CDI Strategies - Volume 4, Issue 16

Q&A: Talk about potential query increases related to ICD-10 implementation

August 5, 2010
Ask ACDIS

Q: What should physicians know now about the level of specificity they’ll be required to document once ICD-10 takes effect? We’re concerned about a potential swell in the number of queries if we don’t begin to address documentation...Read More »

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