Q: What clinical documentation is acceptable to pull Hierarchical Condition Category (HCC) information from for reporting purposes? Would you code from history of present illness, past medical history, active problem list, or the assessment?
Q: If the attending documented, “likely mixed cardiogenic and septic shock,” can I assign codes R57.0 and R65.21?
A: Refer to the documentation within the code book. If you open the book to the R57 code grouping (Shock not elsewhere classified) listed...Read More »
Q: If you have an acute exacerbation of a chronic right heart failure (CHF) with a preserved ejection fraction (EF)— above 55%—can you code it as heart failure with preserved EF? All the clinical symptoms are exemplifying right failure. For example, ascites, pronounced neck vein...Read More »
As part of the seventh annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. James Wall, RN-TN, BSN, MBA, the senior director of clinical documentation improvement at LifePoint...Read More »
As part of the seventh annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Nancy Ignatowicz, RN, MBA, CCDS, a remote/traveling CHI nurse with MedPartners, based in Bourbonnais...Read More »
As part of the seventh annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Rhonda Peppers, RN, BS, CCDS, a CDI specialist at Care Coordinators, MedPartners, in Tampa, Florida...Read More »
As part of the seventh annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Brenda Ng, MS, RN, CCDS, CCS, a CDI consultant at MedPartners in Greenwood Lake, New York, and a...Read More »
Q: I’ve heard lately that outpatient CDI specialists are less likely to be registered nurses. Is there a reason there may be more coders in this arena?
A: While many outpatient CDI specialists do hold an RN credential, there are good reasons for having...Read More »
