Q: I’m running into a big problem with the nursing documentation. The nursing notes have inconsistent documentation of lung assessment, missing documentation when it comes to the patient being on room air or oxygen (O2), and the intakes...Read More »
Q:Should CDI take the criteria from the National Quality Forum (NQF), Agency for Healthcare Research and Quality (AHRQ), and the Centers for Disease Control and Prevention (CDC) into consideration when querying for CAUTI,...Read More »
Q: At my institution, we typically do not capture the pleural effusions noted and documented with a congestive heart failure (CHF) exacerbation unless a pleural tap was completed. Coding Clinic states it is acceptable to...Read More »
Q: I am having difficulty understanding “late effects.” The statement of a “condition or nature of the late effect is sequenced first,” but the code for the acute phase of an illness or injury that led to the late effect is never used with a code for the late effect, seems contradictory...Read More »
Q: If the patient is a Medicare beneficiary, why wouldn’t a MS-DRG associated with the newborns and other neonates major diagnostic category (MDC) not be used? Is it because the patient is more than likely 65 (since they are a Medicare beneficiary) and this MS-DRG is for a newborn/...Read More »
Q: Some CDI specialists tell physicians not to document acute renal insufficiency because it does not code to acute renal failure and I am wondering if that is considered appropriate.
For instance, I was reviewing a chart and the physician documented that the...Read More »