Q: Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase “versus” between them? For example, the patient arrives with abdominal pain and the physician orders labs and other tests but they all come back normal. In the discharge note, the physician documents “...Read More »
To help you start planning your agenda for this year, we’re previewing a handful of speakers throughout the coming weeks to give you a feel for the sessions. This week, we spoke with Tamara A. Hicks, RN, BSN, MHA, CCS, CCDS, ACM, who, along with Melinda B. Matthews, RN,...Read More »
Q: We have a problem getting our physicians to understand what we are querying for (chronic respiratory failure in this instance) when a patient is on home oxygen continuously with documented supplementary oxygen (SpO2) of <90% or arterial blood gas (ABG) with hypoxemia. They tell us...Read More »
Q: I am the only CDI specialist in our 150-bed facility. I have held the position for three years, and am the first one to do so helping to build the position from the ground up. Being the only CDI, I am on several committees, responsible for continual physician education, continuing...Read More »
Q: I am looking for help on reviewing a neonatal intensive-care unit (NICU) death chart for severity ofillness/risk of mortality (SOI/ROM). Prior to birth the child was diagnosed with a severe brain abnormality, holoprosencephaly. The family decided upon comfort care once the baby was...Read More »
Q: Can you please provide me any additional information that supports the option of only offering a single possible diagnosis on a query form? We are working to simplify our query system but are having some difficult discussions regarding whether offering a single diagnosis is “...Read More »
Q: When I started CDI, I was told that when a complication code 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 correct, and is there any written evidence...Read More »
Q: I’m in a little debate: Does documentation of the patient’s body mass index (BMI) need to come from an ancillary clinician like the dietitian or nurse? I thought that we could use ancillary documentation for clinical indicators supporting our physician query but that the...Read More »
