May a physician/provider, who does not take care of a patient during an episode of care answer a query for another physician who did take care of the patient, but does not have time to answer the queries issued to them by the CDI/coders? Could that documented response be used as a basis for...Read More »
I’ve heard that when the volume of surgical cases is flat, any movement in the case mix index (CMI) represents an increased complexity of the patients. Can you explain what that means?Read More »
Q: What advice can you give pertaining to clinical documentation requirements to properly report CPT codes for vaginal deliveries after cesarean procedures?Read More »
I have a question about coding human immunodeficiency virus (HIV) and HIV-related illnesses. If a physician documents a patient is HIV positive, should the chart be coded to Z21? What about if they document the patient is HIV positive with an HIV-related illness—would that be coded to B20?Read More »
I’ve been told that vasodilator therapy can be used to preserve renal function, but I’m having trouble understanding how. Could you explain it to me?Read More »
If Type 2 myocardial infarction (MI) and demand ischemia are both documented, should I code only Type 2 MI based on the Excludes 1 note found in the Tabular List under demand ischemia?
For example, a physician recently documented that a patient had elevated troponin, likely a Type 2 MI/...Read More »
