Q: Is the statement “please document in a progress note to capture the severity of illness (SOI), risk of mortality (ROM) and care needed for this patient” appropriate to use in a query? In general, is it appropriate to mention SOI/ROM and support level of care and profiling when querying...Read More »
Q: A patient came to the emergency department with shortness of breath (SOB). The admitting diagnosis was possible acute coronary syndrome (ACS) due to SOB and elevated troponin levels. The ACS was ruled out. Elevated troponin levels were assumed to be due to chronic renal failure (CRF),...Read More »
Our present hospital policy states that our queries are not part of the medical record. We have several years’ worth of queries and we were wondering if you have a policy on what to do with those.Read More »
Q: How should the diagnosis of urinary tract infection (UTI) and encephalopathy be sequenced, specifically which diagnosis should be the principal? If physician documentation indicates that the patient came in with confusion, can encephalopathy be assigned as the principal diagnosis if it...Read More »
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 »
