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 »
Q: I have a question about the following query. If the response is B, can you still capture it as withdrawal?
Based on these indicators taken from the medical record, please clarify by documenting on this query form and/or in the progress note the condition...Read More »
After several years working as an agency nurse, doing a little bit of everything, from occupational health to psychiatric to home health to case management, Jessica Ward RN, BSN, C-CDI CDI specialist at Madison Health in London, Ohio, was ready for a change.Read More »
Q: The 2016 CDI Pocket Guide states that four or more stents or vessels is equivalent to an MCC and changes the DRG. I understand that Coding Clinic, Second Quarter 2015 defines the number of individual sites instead rather than anatomical vessels. The DRG Expert...Read More »
Q: At my facility, we are to “pull” bad or un-credible queries from patient charts and report the query to our manager. Is there any official guidance on this practice?Read More »
