Q: We recently reviewed a troubling case related to sepsis core extractions which revealed that the patient did not have sepsis and the physicians did not document sepsis as there was no bacterial infection. The CDI specialist, however...Read More »
Q: After a video-assisted thorascopic surgery (VAT) procedure, a patient is usually receiving high flow oxygen. What circumstance might prompt a CDI specialist to query for acute respiratory failure in this situation? Read More »
Q:I’ve heard some conflicting advice regarding code group B95-B97, bacterial and viral infectious agents. I’ve heard that those codes don’t provide a CC or MCC as a secondary diagnosis in most cases. I’ve also heard that...Read More »
Q:How would you determine if the treatment is for the initial myocardial infarction (MI) as a secondary diagnosis versus the treatment for the subsequent MI?
Q: A patient with documented acute respiratory failure, could have both confusion and somnolence, but should both confusion and somnolence be coded? When should the symptoms be coded? For example, with a patient who has abdominal pain...Read More »
Judy Cassetty, BSN, RN, CCDS, and Sylvia Emery, MSN, RN, RHIA, CCS, CCDS, will be presenting “Educator supporting roles in a highly advanced CDI model that drive change,” on Day 1 of the ACDIS conference.Read More »
Q: If the principal diagnosis is pneumonia, do I need to also code the symptom dyspnea? Or, is the dyspnea integral to the pneumonia? A: If the dyspnea (and as other...Read More »
Q: If a patient is admitted for anemia related to a malignancy and is treated only for anemia, the principal diagnosis goes to the malignancy. I understand that the malignancy was the root cause of the condition making it the principal...Read More »