Q: I have a general question about how providers should list their primary and secondary diagnosis in their daily progress notes. I was taught the primary diagnosis should be listed as number 1 (first listed diagnosis) and then the other...Read More »
Jaime Baker Sherman, RN, BSN, CCDS, is a CDI Quality Oversight Specialist, at the University of Iowa Hospitals and Clinics (UIHC) in Iowa City.Read More »
Q:We recently had a patient who was admitted with sepsis POA and a UTI. When the chart was coded, UTI was listed as the principal diagnosis. I was under the impression that when sepsis is POA, it should always be coded as the...Read More »
Q:Often, we get caught up on some clinical indicators that potentially introduce encephalopathy, for example, if patient has vascular dementia or other structural issues that might contribute to encephalopathy. Can you help...Read More »
Ever wonder how your CDI program ranks in terms of physician query responses? Wondering if your facility is the only one that struggles to reduce the number of doctors who habitually answer “unable to determine” as a means to bypass supporting CDI?Read More »
Q: What is the difference between ICD-10-CM code I24.8 (other forms of acute ischemic heart disease) and code I21.A1 (myocardial infarction type 2)? In which situation would each of these codes be reported? Read More »
Q:The coders at our facility recently asked CDI to teach the providers to write EtOH use “disorder” or cocaine use “disorder,” so that they can code it to EtOH abuse and cocaine abuse. Do you agree with this request from the...Read More »