Q: I am looking for additional clarification regarding the recent AHA Coding Clinic for ICD-10-CM/PCS concerning diabetes and the use of the word “with.” While the examples often used in Coding Clinic are specific, the actual...Read More »
Q: As part of an integrated access management program, what medical documents are needed to perform a medical necessity review so that the access care coordinator (ACC) can offer a level of care recommendation to the physician?Read More »
Q:I was reviewing a case with one of our CDI specialists this morning. Briefly, the following clinical indicators documented in the chart are elevated cardiac enzymes, shock, and demand ischemia. Cardiology documented “elevated cardiac enzymes in setting of shock representing a...Read More »
Q:We are getting pressure from our othopods to send all queries to their nurse practitioner (NP). Our facility bylaws allow NPs to function independently and they are allowed to answer queries without co-signature, so we routinely send queries to NPs who are caring for...Read More »
Q: We have a teenager with systemic lupus erythematosus (SLE) and history of lupus nephritis who came into the ED with seizures. The physician admitted the patient with documentation of with status epilepticus and hypertensive urgency. The intensivists then documented hypertensive encephalopathy...Read More »
When Karen Elmore, RN, BSN, CCDS, documentation quality coordinator at Boone Hospital in Columbia, Missouri, was asked to help start a CDI program at her facility nearly eight years ago, she knew her background as a nurse educator would pay off.Read More »