Q: How would the following be viewed if it was included in a cardiology consult note:
“Mr. X has paroxysmal atrial fibrillation. He had a recurrence last night which was asymptomatic. We think this happens all the time at home. This is not a pacing...Read More »
Q:In my facility, we are supposed to send an e-mail to our physician advisor (PA) and to administration if a query is not answered within a week. However, this policy doesn’t work well because administration does not do anything with that information, and the PA doesn’t...Read More »
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 physician documents “...Read More »
To help you start planning your agenda for this year, we’re previewing a handful of speakers throughout the coming weeks to give you a feel for the sessions. This week, we spoke with Tamara A. Hicks, RN, BSN, MHA, CCS, CCDS, ACM, who, along with Melinda B. Matthews, RN,...Read More »
Q: We have a problem getting our physicians to understand what we are querying for (chronic respiratory failure in this instance) when a patient is on home oxygen continuously with documented supplementary oxygen (SpO2) of <90% or arterial blood gas (ABG) with hypoxemia. They tell us...Read More »
Q: I am the only CDI specialist in our 150-bed facility. I have held the position for three years, and am the first one to do so helping to build the position from the ground up. Being the only CDI, I am on several committees, responsible for continual physician education, continuing...Read More »
Q: I am looking for help on reviewing a neonatal intensive-care unit (NICU) death chart for severity ofillness/risk of mortality (SOI/ROM). Prior to birth the child was diagnosed with a severe brain abnormality, holoprosencephaly. The family decided upon comfort care once the baby was...Read More »
