Q: A question came up with our staff regarding if we should be querying for linking terms using the term “with” such as “Foley with UTI.” Is the documentation of “Foley with UTI” appropriate to indicate a CAUTI when not present on admission since the word “with” assumes a...Read More »
Q: I’ve heard that the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria cannot be applied to diagnose malnutrition based solely on the dietitian’s documentation. Can you please elaborate on why this is the case?Read More »
Q: I know that CMS doesn’t classify morbid obesity as a comorbid complicating condition (CC) as a secondary diagnosis. Can you please explain why? What diagnoses are classified as CCs by CMS in terms of obesity?Read More »
Q: I recently heard an example where a patient with a principal diagnosis of lower extremity deep vein thrombosis (DVT) and myocardial infarction, which was not present on admission. In the example, they said that this case would go to DRG 282, Acute myocardial infarction (AMI...Read More »
Q: I had a recent case where the nephrologist and cardiologist both documented hypertensive (HTN) emergency, but the attending documented HTN urgency. The attending was correct based on clinical indicators. Does that mean I don't have to query the attending and can just take...Read More »
Is there a list or guidelines for what terminology is considered adequate to establish a link between two conditions, similar to the uncertain diagnosis list?
Would the example above of “GI bleed in the setting of anticoagulants” be sufficient
