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 »
