Q: I have a patient with Stage 4 lung cancer that presented with fatigue, cough, and loss of appetite. Initially, the physician documented possible pulmonary nodular amyloidosis (PNA) but following an echo-cardiogram on day one they found a pericardial effusion (malignant). The...Read More »
Editor’s note: Over the coming weeks leading up to the conference, we’ll take some time to introduce members to a few of this year’s speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. For today’s Q&A, we caught up with ...Read More »
Q: We are having trouble determining how to assign a code for a pressure ulcer that begins as a Stage I concern that is present on admission (POA) but advances during the patient’s stay to a Stage II or a Stage III. Coding Clinic, Fourth Quarter 2008, p. 194, tells us that even if...Read More »
Q: Can you clarify the expectations related to documenting the discussion between a physician and a CDI specialist when a query is done verbally. The 2013 ACDIS/AHIMA physician query practice brief ...Read More »
Q: In the past few weeks, we noticed physicians are documenting acute congestive heart failure with preserved ejection fraction (EF), instead of diastolic or systolic. In speaking with the physicians, they say the heart failure is not diastolic or systolic. What is the best way...Read More »
