Q:Would there be any legal or ethical issue if a CDI nurse did the discharge summery for a group of physicians and then they agree and sign off on them?Read More »
Charlene Compher, PhD, RD, LDN, FASPEN, and Richard Pinson, MD, FACP, CCS, will present “GLIM: The New Malnutrition Clinical Criteria and Implications for the CDI Profession,” on Day 1 of the ACDIS conference. Compher is a professor of nutrition science at the University of Pennsylvania School...Read More »
Q:Is it a coder’s responsibility to properly sequence secondary diagnoses or is this a process that happens when the codes are transferred to the super bill? My concern is with making sure that heavily weighted secondary...Read More »
Q:We recently had a patient who had a syncopal episode and fell, sustaining head trauma with a resultant SAH. What is the proper coding and principal diagnosis? Is this traumatic SAH with loss of consciousness or SAH with...Read More »
Bettina Sonen, RN, CCDS, is a clinical documentation educator at Northeast Georgia Health Systems (NGHS) in Gainesville, and she is a member of the Georgia ACDIS local chapter.Read More »
Q: I’ve heard that an increase in the volume of surgical cases can increase a facility’s overall CMI and that when the volume of surgical cases is flat, movement in the CMI represents increasing complexity of patients cared for in that facility...Read More »
Q: Could you shed some light on the codes of K66.1, retroperitoneal hematoma, an MCC, and R58, retroperitoneal hemorrhage, which is not considered a CC or an MCC? If both are documented within the same medical record, is this considered a...Read More »