Q: If an echocardiogram shows a type of trace/mild/moderate regurgitation, is that enough to query for that diagnosis? Or is this considered an insignificant finding?Read More »
Can you please discuss right heart failure and its relationship to pulmonary hypertension instead of diastolic heart failure. For example, established diagnosis of heart failure and methamphetamine intoxication, established diagnosis of heart and smoke inhalation or carboxyhemoglobinemia, or...Read More »
When I was trained as a new CDI specialist, I was told that I could query for hyponatremia with two low sodium (NA) values as a clinical indicator as it shows that while it is not necessarily being treated, hyponatremia is being monitored.
A recent conversation with a senior CDI...Read More »
Q: When is it appropriate to code both flash or acute pulmonary edema and acute on chronic heart failure (diastolic, systolic, or other)? What other etiologies lead to flash pulmonary edema and how do I know when to query?Read More »
Our facility has adopted a systemwide definition of sepsis (based on Sepsis-3) and we’re having success with educating most providers. Some of our infectious disease providers, however, like to use the term septicemia which codes to A41.9, Sepsis, unspecified organism. This is somewhat of a...Read More »
What are some ways to assist with mortality reviews in order to identify missed opportunities and increase the severity of illness (SOI)/risk of mortality (ROM) scores for the case?Read More »
If a patient safety indicator (PSI) would be excluded because a procedure was emergent, do you still capture the code that would have triggered a PSI?Read More »
Q: Our dietitians send cases needing a query for malnutrition to our CDI staff. Previously, they were notifying providers of the need for the documentation of the diagnosis directly, but from a compliance perspective, they were more comfortable with us owning the formal query...Read More »