Q: According to a denial letter, acute metabolic encephalopathy secondary to any disease (which it obviously always is) codes to G94, other disorders of brain in diseases classified elsewhere. The auditor stated to “Please see code category G93.4 which has an excludes 1 note excluding “...Read More »
Q: What should we do about the documentation of “acute pulmonary insufficiency?” What indicators are you using for this in comparison to querying for acute respiratory failure? Acute pulmonary insufficiency is an MCC following surgery but it is also a potential patient safety indicator (...Read More »
Q: When looking at denials timelines, what information should be noted?
A: There are many critical time elements to capture during the denial appeals process. It is recommended that you add these to your denials database. If that is not possible, an...Read More »
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 »
