Q:If the patient comes in with a high blood alcohol level and the provider documents that number in their note, do they also need to specifically write “patient with intoxication?”Read More »
I love the show MythBusters, even though there are times I just can’t believe their conclusions. For example, I raised my kids believing the infamous five-second rule, and they seemed to have survived quite well...Read More »
Q: I need some help understanding severity of illness (SOI) and risk of mortality (ROM) as it’s my first encounter with APR-DRG factors that may affect reimbursement. First, how does one measure the SOI and ROM? Could you elaborate on how complications or comorbidities (CC) and major CCs...Read More »
Q: I have a number of questions related to strokes, but essentially, can you describe the clinical definitions of stroke and explain what CDI professionals should be looking for in the medical record?Read More »
Kathie McAlexander, RN, CCDS, works at the University of Mississippi Medical Center in Jackson, Mississippi, and has been in the CDI field since 2002.Read More »
Q: If an uncertain diagnosis is only documented by a consultant consistently through the medical record, including in the last progress note, and is left out of the discharge summary, should that diagnosis be coded?Read More »
