ACDIS developed the Certified Clinical Documentation Specialist-Outpatient (CCDS-O) to provide a trusted baseline of competency for CDI in the outpatient setting, which includes physician practices, hospital clinics, and the emergency department, among other settings. Currently, the CCDS-O exam...Read More »
Q: We had a physician document metabolic encephalopathy on a post-operative patient who was sedated on a vent. Prior to the surgery, the patient was alert and oriented to person, place, time, and event. Post-extubation one day later, they were alert and oriented to person, place,...Read More »
Q: Does your team include calculations to support clinical indicators in your queries? Do your CDI specialists calculate P/F ratio and include the calculation in their query addressing respiratory failure? Do your CDI specialists calculate the corrected sodium level for...Read More »
Q: Do you query for acute pulmonary insufficiency? If so, what criteria do you use?
Response #1: We have recently begun to educate our providers (especially cardiothoracic surgeons) on using this diagnosis. We tell them to utilize it for...Read More »
Q: What criteria guidelines are you utilizing for sepsis (i.e., Sepsis-2, sequential organ failure assessment [SOFA], etc.)? Do you adjust criteria based on payer? We’re currently using Sepsis-2 for all payers.
Q: A 64-year-old female inpatient has hepatocellular cancer with an orthotropic liver transplant with bile duct obstruction and is immunosuppressed due to drugs. Which ICD-10-CM codes would be reported?
A: The scenario would be reported with ICD-...Read More »
