What are the requirements when it comes to a physician advisor asking for diagnoses to be added to the medical record? Based on the ACDIS/AHIMA “Guidelines for achieving a compliant query practice” brief, physician advisors follow the same requirement of a CDI specialist with a compliant...Read More »
Our query process currently creates a physician progress note when a query is answered which becomes part of the permanent medical record. We do keep the original query as well, which clearly identifies the query author and it is discoverable, but not as part of the medical record. We included...Read More »
I believe there was a Coding Clinic several years ago where the diagnosis of “mental incompetence” was changed to “intellectual disability,” but I can’t seem to locate it. What ICD-10 code should be used if a person is documented as “mentally incompetent”?Read More »
How can real-time chat function in an electronic health record (EHR) be used? Are CDI specialists and physicians receptive to a real-time chat?Read More »
Recently, we’ve seen an uptick in clinical validation denials regarding acute pulmonary insufficiency and acute respiratory failure following surgery. What can we do to fight or prevent denials for these diagnoses?Read More »
Are institutions appealing sepsis denials if the patient meets sepsis-2/super systemic inflammatory response syndrome (SIRS) criteria, but not sequential organ failure assessment (SOFA) criteria? We have one hospital in our system that uses only sepsis-2 as their criteria, and many of them have...Read More »
When faced with a body mass index (BMI) denial, I have used the following Coding Clinic references with no luck:
Coding Clinic, Fourth Quarter, 2018, p. 77: "obesity and morbid obesity are always clinically significant and reportable when documented by the provider. In