Q: We recently had a situation where a 72 year old was admitted with large pleural effusion, fever, elevated white blood cell count, and a left shift. The provider also documented acute respiratory failure.
Q: An intoxicated patient comes into the emergency department with a history of alcoholism and the physician prescribes precautions for withdrawal and documents “tremors.” Can we assume that the physician means “delerium tremors” or “DTs”?...Read More »
Q: At what stage should an established program most likely experience a reimbursement plateau? One may naturally expect the physicians to improve as CDI programs hammer them with education. After we’ve gathered all the low-hanging fruits and go for the mangos? We ran the top principal...Read More »
Q: I am part of a fairly new CDI department trying to amp-up our physician education/guidelines. To that end, I have been reviewing the Academy of Nutrition and Dietetics (the Academy) and the American Society for Parental and Enteral Nutrition (ASPEN...Read More »
Q:If the physician writes septic shock instead of sepsis do I need to query for sepsis or is this an integral part and sepsis would be the principal diagnosis and the septic shock would be secondary, making it a MCC?
Q: When a provider states that the patient is admitted rule out (R/O) a myocardial infarction (MI) would the MI get coded as though it exists?Read More »
Q: The majority of the admissions I am reviewing this week are for an elderly population. It seems that they all have the same admitting diagnoses: Failure to thrive (FTT), urinary tract infection (UTI), fever, dehydration, altered mental status...Read More »
Q: With electronic health records, many times the attending provider will “pull” the pathology or radiology report into their note and sign the note. What further documentation would be needed in order to code from this, which is now part of the attending provider’s note but was...Read More »
