Q: We’re attempting to make provider queries part of our medical record which coding can use to pick up codes. Does anyone have experience with this they could share? We are interested in: Components of a query (complaint query), who to send the query to, who is responsible for...Read More »
Kaitlyn Loffreda, BSN, RN, CCDS, is a CDI team lead at Penn State Health in Pennsylvania. She has been in the field since 2017 and is a member of the central Pennsylvania ACDIS local chapter.
ACDIS: What did you do before entering CDI, and why did you get into...Read More »
Q: Are coders required to report a social determinants of health (SDOH) ICD-10-CM code when a CPT code for an evaluation and management (E/M) service level is based on medical decision-making (MDM)?Read More »
Q: What terms need to be included in physician documentation to code in ICD-10-CM whether the patient’s migraine is chronic, intractable, or with status migrainosus?
A: “The patient has a migraine,” is insufficient documentation. Let’s...Read More »
Tracy Gapinski, BSN, RN, CCDS, is a CDI specialist lead at Community Healthcare System in Valparaiso, Indiana, and is associated with the Indiana ACDIS chapter. She has been in the CDI field for six years now.
ACDIS: What did you do before entering CDI? ...Read More »
Q: I have a couple of questions regarding CDI metric expectations, reporting, and education for your CDI teams. I have been working on a CDI metrics report of the expected systemwide versus individual query rate, review rate, physician response rate, agreement rate, and expected...Read More »
