Q: If the physician says “concerning for,” “considering,” “cannot be ruled out,” or “cannot be excluded” for a diagnosis is that considered an uncertain diagnosis? Can those terms be coded if the patient is being worked up? Are the terms “concerning for” and “considering” equal to the “...Read More »
Q: I have been asked to build a query for a diagnosis of SIRS and/or sepsis for the following scenario: The patient was admitted for an infection urinary tract infection (UTI), pyelonephritis (PNA) and meets two SIRS criteria. The patient may be treated with oral or intravenous...Read More »
There’s less than a month left to receive the early bird rate ($805 member, $905 non-member) for the . Don’t miss your chance to save! To view the conference brochure and agenda, click...Read More »
Q: Could you please explain unrelated surgical procedure DRGs? Also can you explain how we can differentiate between extensive operating room (OR) procedure and non-extensive OR procedure. Read More »
Q: When I started as a CDI specialist, I learned that when a complication code, such as 999 or 998 series, happens to be the reason of admission, along with another condition also contributing to the admission, the complication code takes precedence over the other condition code. Is this...Read More »
Q:What information do you have about physician response to ICD-10-PCS? I am getting some push-back from surgeons. The response I received from a surgeon was, “I want to choose my own words for the surgery that I performed” and “I don’t want a coder picking the words, ‘removal or...Read More »
Q: When did the CDI program at Wake Forest University Baptist Medical Center start getting involved in looking at quality-related documentation concerns and what was the impetus for the evolution?
A: It started with pressure ulcers. Back in 2011/2012 the...Read More »