Q: What are the most common reasons postpartum hemorrhage is documented and coded inconsistently, and how can coders and clinicians help address these issues?
A: As one of the top five causes of maternal mortality worldwide, postpartum...Read More »
Q: What are some documentation gaps in behavioral health encounters?
A: Many times, we see a lack of specificity regarding symptoms, severity, and treatment details required for accurate ICD-10-CM coding, as well as incomplete...Read More »
Q: If a provider answers a query and the response requires further clarification, is it compliant to contact the provider by phone or other outside query method, have a conversation with the provider, and then ask/encourage them to add to their note without documentation regarding...Read More »
Q: I primarily work in the neurosurgery review lane within CDI and am seeking further guidance on best practices for capturing loss of consciousness (LOC) status in cases of traumatic subdural or subarachnoid hemorrhage. Current definitions of LOC appear broad and can be challenging...Read More »
Q: What are some documentation gaps in behavioral health encounters?
A: Many times, we see a lack of specificity regarding symptoms, severity, and treatment details required for accurate ICD-10-CM coding, as well as incomplete...Read More »
Q: How are outpatient consultations reported? And what qualifies as a consultation?
A: Outpatient consultations are reported with CPT codes 99242-99245. Each has a time and a level of medical decision-making (MDM). You report either the time or MDM. Here's an overview:...Read More »
The ACDIS offices will be closed until Monday, January 5. We hope you’re spending time recharging as we enter the new year as well. While we’re out, we wanted to provide you with our top CDI Strategies articles from 2025. This year, we published 57 editions of CDI Strategies, ...Read More »
