Q: May a physician/provider, who does not attend the patient during an episode of care but does act in an advisory capacity for the CDI and/or coding departments, answer a formal query? Could that documented response be used as a basis for compliant code assignment?Read More »
Q: What are other facilities doing to avoid denials on the back end and code the chart accurately the first time with a clinically supported diagnosis?
A: You bring up an excellent point. If the clinical indicators do not seem to support the diagnosis, it is the responsibility of the CDI/...Read More »
Q: Can CDI programs use information on ambulance forms or trip tickets to abstract from if the information is pulled into or reiterated in the ED or history and physical (H&P) documentation? Our staff doesn’t want to miss criteria that would diminish our ability to substantiate the...Read More »
Q: Our facility is considering having our coders and CDI specialists “go–live” with ICD-10-CM/PCS on July 1, in order to practice to help off-set the impact of ICD-10. The system will would then code backwards into ICD-9-CM for billing. Is this “backward mapping” method appropriate?Read More »
Are records with only one MCC noted targeted by Recovery Auditors or other audit agencies? I am confused because I have also heard that it’s good to capture one MCC.Read More »
The role of CDI programs grew out of the coding specialty. Knowledge of coding practices is a very important skill for the CDI specialist. CDI specialists do need to understand the basic tenets of code assignment, and follow the rules and regulations governing the coding process.Read More »
Editor’s Note: James S. Kennedy, MD, CCS, CDIP,director of CDIMD Physician Champions offers the following perspective on a Q&A originally published in the December 18, 2014, ...Read More »
Q: What is ACDIS’ stance on physicians cutting and pasting the entire radiology report into their progress note? Are we allowed to take diagnoses from this documentation? Can the physician cut and paste the radiological findings from the report into their progress notes? Or is this, in...Read More »