We’re having a lot of discussions lately on whether we should query for pressure injuries when they’re only documented by nursing. Our wound care nurses determined that staff nurses identify pressure injuries correctly only 60% of the time. If we’re querying based on nursing documentation, our...Read More »
I recently listened to a webinar where treatment was emphasized especially for diagnoses such as sepsis, acute respiratory failure, and severe protein calorie malnutrition. How much emphasis should CDI professionals put on treatment?
For example, can we count treatment from a dietician’s...Read More »
Our providers tend to use the term “RDS” in their documentation to describe all “respiratory distress,” “respiratory distress syndrome of newborn,” and “acute respiratory failure.” Often, we find ourselves querying to clarify/remove RDS when it is in fact respiratory distress and not respiratory...Read More »
According to our software vendor, you can only code liver lacerations as minor, moderate, or major. According to all the educational materials I can find, however, liver lacerations are on a grading scale (grades 1-5). How does your institution code the liver laceration if they only give...Read More »
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 »
