Rita Fields, BSN, RN, CCDS, recently retired from her role as regional CDI manager at Baptist Health in Louisville, Kentucky, and was named CDI Professional of the Year in 2017. Susanne Warford, MBA-HCM, RN, CCDS, is the system CDI analyst and appeals nurse for Baptist Health in Louisville,...Read More »
Q: I recently was reviewing a chart where the infection control physician stated the patient had sepsis, but the attending listed bacteremia as the diagnosis. I sent a query to clarify which was correct and the attending confirmed bacteremia. On the...Read More »
Autumn Reiter, BSN, RN, CCDS, CDIP, CCS, director of CDI services for TrustHCS, based in Springfield, Missouri, will present “Five Pillars for Building a Successful CDI Program in Emergency Services and Other Outpatient Areas,” on Day 1 of the ACDIS Symposium: Outpatient CDI....Read More »
Q: What do you suggest the providers write to describe medication/substance overdose? In my experience, physicians don’t write “poisoning” in these cases. Read More »
Q: I’ve heard that if a condition cannot be identified as POA, it will not keep the criteria for a principal diagnosis and cannot be sequenced as such. I recently had a patient who was admitted for syncope and all the workup was negative, but it’s...Read More »
Richard Pinson, MD, FACP, CCS, is a principal and co-founder of Pinson and Tang, LLC. Dr. Pinson will be presenting on Day 2 of the 2018 ACDIS Symposium: Outpatient CDI. The title of his presentation is “Diabetic complications...Read More »
Q: During a final pre-bill coding review, the coding leader identifies a CDI initiated query that does not meet the ACDIS/AHIMA guidelines for a compliant query. But, the physician has already responded to the query with a diagnosis which was then...Read More »
Q: We recently had a situation where a patient was admitted for syncope workup and all the workups were negative except for incidental findings of AKI. The physician documented “AKI likely 2/2 hypovolemia. Treatment focus is to trend creatinine levels...Read More »