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 »
Editor’s note: Nicole F. Draper, RN, BN, MHA, DH-C, is the manager of length of stay, documentation, and revenue optimization at St. Vincent’s Private Hospital Sydney in Darlinghurst, New South Wales, Australia. She presents “Measuring clinician engagement: The journey to...Read More »
Editor’s note: Cheryl Ericson, MS, RN, CCDS, CDIP, is the manager of clinical documentation services at DHG Healthcare in Charleston, South Carolina. She is a CDI subject matter expert for a variety of industry publications and keeps...Read More »
Editor’s note: Cesar M. Limjoco, MD, and Kelli A. Estes, RN, CCDS, will be presenting “The ultimate test for queries,” on Day 1 of the ACDIS conference. Limjoco is the vice president of DCBA, Inc. in Indianapolis, Indiana....Read More »
Q: Does sepsis and/or severe sepsis have to be documented in the medical record when only septic shock is noted? We have a couple of physicians that will document septic shock without noting sepsis and/or severe sepsis. I was informed that coding needs to also have the documentation of...Read More »
Q: The revenue officer at our facility says all death charts should have a CC/MCC. I do try to find missed CC/MCCs on the records as well as the complete documentation, however, not all records end up having one. Can you help me understand the basis of this requirement and give me some...Read More »
