Q: The physician documented “encephalopathy” in the record of a patient who was admitted with a cerebral vascular accident (CVA)and/or possible seizures. The patient was confused but has returned to baseline. Are these conditions considered interrelated or can we code for the...Read More »
Q:When I started as a CDI specialist, I learned that when a complication code, such as 999 or 998 series, happens to be the reason of admission, along with another condition also contributing to the admission, the complication code takes precedence over the other...Read More »
Q: If a is patient admitted with malnutrition and the physician documented the patient to be malnourished from mild to severe, would the CDI team use DRG 641, Severe Malnutrition as a working DRG, or should we query the physician to clarify the severity or type of malnutrition?Read More »
As you put the final touches on your itinerary, we have a couple more speaker previews that we’d like to share with you. This week, we spoke with Allison Clerval, RN, BSN, CCDS and Kathleen M. Shindle, RN, BSN, CCDS, who will present “A Matter of Life and Death: CDI Impact on Mortality Risk...Read More »
Q: I work in a large, provider-based orthopedic clinic with a rheumatology department that has many patients who are very ill with several comorbid conditions. Does the physician need to document every comorbid condition that impacts his or her medical decision making for each encounter?...Read More »
Q: Although I understand that a coder cannot code from a previous encounter’s documentation, can the CDI specialist bring information to the physician’s attention such as laboratory results in order to obtain a baseline for renal failure/chronic kidney disease (CKD)?Read More »
As you put the final touches on your itinerary, we’re continuing to preview some of speakers to give you a feel for this year’s sessions. This week, we spoke with Kelli A. Estes, RN, CCDS, who, along with Cesar M. Limjoco, MD, will present, “Go After the Truth,...Read More »
Q: Should I query for chronic respiratory failure if the documentation indicates the patient has sleep apnea and is being treated with continuous positive airway pressure (CPAP) at night?
A: I love where you are going with this question, it demonstrates your critical...Read More »
