Q: If a provider answers “yes” or “no” to a yes/no query on the actual query template, does the provider also need to document their diagnosis in a note? If the query is part of the permanent medical record, does that answer on the query template suffice and eliminate the need for...Read More »
Question: I am a little confused regarding the meaning “clinically undetermined” or “unable to determine” as a query choice. If a physician chooses unable to determine, does it mean the provider disagrees with the presented choices or disagrees with a diagnosis entirely? For example...Read More »
Q: If the radiology or pathology report stated ovarian cancer but the physician never documented an ovarian mass, is it true you can’t use a present on admission (POA) query to capture the ovarian cancer because the physician made no reference to it? Would you need to use either an...Read More »
Q: We currently use a staffing ratio of one CDI specialist to 1,900 discharges, but I feel this is very outdated as we are now doing quality and clinical validity. Will anyone share your ratios that their CDI also covers quality and clinical validity and at times...Read More »
Q: I have a question regarding acute organ dysfunction. If a provider documents “hyperbilirubinemia related to severe sepsis with acute organ dysfunction,” will this suffice for coding acute organ dysfunction, or should I query for a more definite diagnosis?
Q: We recently had a patient who presented with a stage 2 pressure ulcer. Due to hypoperfusion, the pressure ulcer progressed. The physicians are now documenting progression due to “skin failure” due to hypoperfusion. Can you have skin failure at the same site of a pressure ulcer, or...Read More »
Q: A four-year-old managing lissencephaly, hypotonia, and dysphagia with aspiration of secretions presents with fever and tachypnea. A chest x-ray shows right lower lobe infiltrates. Would it be appropriate to query the provider to confirm a diagnosis of pneumonia?...Read More »
Q: As we plan to update our CDI productivity policy, I wanted to check how others calculate their productivity. Do you include initials (new accounts), subsequent (in-house re-reviews), and Retro (Discharge accounts, mainly to reconcile queries)? Or just initials (new accounts),...Read More »