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...Read More »
Editor’s Note: Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, MCP, presents “Integrating CDI processes with the EHR: Getting it right from the beginning,” on Tuesday, May 22 at 3:15 p.m., in Track 7, Leadership and Department Management. The follow Q&A was conducted by ACDIS Member...Read More »
Q:Could you please explain unrelated surgical procedure DRGs? For example, a patient with a principal diagnosis of pneumonia whose surgical procedure transurethral resection of the prostate (TURP), MS-DRG 168. Also can you explain how we can differentiate between...Read More »
Q: I realize that if the body mass index (BMI) of a patient is documented by nurses and dieticians, it can be coded if the physician documents the clinical significance (i.e., morbid obesity). However, if the BMI is documented by a patient care tech or nursing ward secretary in...Read More »
Q: The physician documented mild bronchitis treated with Zithromax in the progress note on day two of the patient’s hospital. I looked for clinical indicators and the only documentation I found in the nursing notes was that the patient had a non-productive cough on admission. ...Read More »
Q: Is it true that a CDI physician advisor/champion cannot be a direct patient care provider?
A: CDI departments are not required to have a physician advisor; however, it is beneficial to have a physician champion. I make a distinction between the two...Read More »
Q:We have a problem getting our physicians to understand what we are querying for (chronic respiratory failure) when a patient is on home oxygen continuously with documented supplementary oxygen (SpO2) of <90% or arterial blood gas (ABG) with hypoxemia documented....Read More »
Q: How are staffing needs expected to change in relationship to ICD-10?
A: I’m not aware of any benchmarks for CDI staffing in consideration for ICD-10. There is so much diversity among CDI departments and their responsibilities regarding ICD-10 that it is hard to establish any...Read More »