Q: Over the years I have heard differing opinions regarding whether clinical or coding expertise should be weighed more during the concurrent record review process. I have been told many times to “think like a coder,” and “not get to clinical when you are looking at the chart.”...Read More »
Q: Is it is okay to alter, add to, or take back a query form after the physician answers it?
A: There are two basic situations that support the need for a query. The first and most common situation is when there is evidence of an incomplete, vague, or missing diagnosis...Read More »
Q: I am new to the CDI role and looking for suggestions as to how to work with our surgeons to help them beef up their documentation. Do you have any suggestions?Read More »
Q: I am a relatively new CDI specialist in a relatively new CDI program. We learned that we should be examining the health record with an eye toward “what bought the bed.” When we raise this concept to our coders, however, they disagreed with the premise telling us that such a concept was...Read More »
Q: We are implementing a new electronic CDI system. Our concurrent queries are not currently a part of the medical record. The providers document their responses in the progress notes. We believe this adds to the consistency of the medical record and will avoid any issues related to...Read More »
Please clarify the rule regarding presumption of the link of diabetes, when documented, to the diagnosis of osteomyelitis when both are documented by the provider.Read More »
Q: We recently admitted a 52-year-old man who was waiting for a liver transplant. He has a history of hepatitis C, chronic back pain, and drug and alcohol abuse. He was found unresponsive at home in a pool of vomit. The toxicology screen on admission was positive for benzodiazepine,...Read More »
Q: I am a relatively new CDI specialist in a relatively new CDI program. We learned that we should be examining the health record with an eye toward “what bought the bed.” When we raise this concept to our coders, however, they disagreed with the premise, telling us that such a...Read More »
