Q: Recently, we’ve seen a few situations in which respiratory failure was present on admission (POA), but then later in the stay, the patient’s condition progresses to acute respiratory distress syndrome (ARDS) or the physician determines that it is ARDS. In these situations, our coding team is...Read More »
Q: We’re having some trouble with malnutrition documentation. In many instances, the patient meets the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria and the provider agrees with the query, but then doesn’t expand on the diagnosis in their documentation. We’re then...Read More »
I’ve always thought that, as long as the clinical indicators support the condition you’re querying for, providing all the options for the specific type/specificity of that condition allows the provider to use their clinical judgement. Is this correct?Read More »
If a patient is admitted with both gram-negative pneumonia and acute respiratory failure, which should be sequenced as the principal diagnosis?Read More »
Dawn Valdez RN, LNC, CCDS, CDIP, joined the ACDIS team officially at the beginning of 2020, as a full-time CDI education specialist. Since then, she’s been busy getting up to speed, hitting the road with Education Director Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC, and...Read More »
Q: What’s the best way to approach CDI rounding with providers? We are considering implementing this practice and are looking at processes, outcomes, lessons learned, etc. Read More »
