If the primary diagnosis is cerebral vascular accident (CVA), can we have a secondary diagnosis of hemiplegia to add a CC? Or is this considered in the same Major Diagnostic Category (MDC), diseases and disorders of the nervous system?Read More »
We had a patient with Type 2 diabetes who was admitted for hypoglycemia with metabolic encephalopathy. The patient also had stage 2 chronic kidney disease (CKD) and a diagnosis of hypertension (HTN). Which ICD-10-CM codes should we assign for this patient’s encounter?Read More »
It was amazing to see the host of vendors, volunteers and attendees at last week’s California ACDIS Chapter meeting. The leadership team hosted a meet-and-greet the evening before at a Davis (CA) brewery were early arrivers could mingle and nosh on tasty tacos from a regional food truck. The...Read More »
Q: Our organization is considering outsourcing some of our CDI staffing to help us out when we have full-time employees off on extended leave or paid time off. Additionally, the outsourced staff would be helping with some specific review areas. Before we pursue this, I had some questions:...Read More »
According in the preliminary 2019 CDI Salary Survey results, 51.57% of CDI specialists (those whose primary role is record reviews) make between $70,000 and $89,000 per year, up from 45.49% year-over-year.Read More »
As part of the tenth annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Susan Sweeney BSN, RN, CCS, CCDS, CDIP, a CDI consultant for Covenant HIM Consulting, and a member of the 2020...Read More »
Q: I’ve heard conflicting information about coding uncertain diagnoses. Do they need to be documented in the discharge summary/final progress note, or can they be coded from an earlier progress note?Read More »
