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 »
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 »
