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 »
Q:I often find CHF listed under past medical history. Frequently, the patient also has HTN and CAD, so they’re on medications. When I query for the type of CHF, the providers sometime document “no CHF.” I’ve heard before,...Read More »
Q:I have a patient with a UTI with pyuria and an elevated WBC count. There’s also recurrent plugging of the urine catheter secondary to sediment. I know the term “with” can link two diagnoses, but that it does not represent a...Read More »
So, you’ve worked hard at physician engagement and your physician response rate is stellar. But, how many of those providers actually carry through the queried diagnoses through to the daily progress notes? This is the question...Read More »
