Physician Advisor Corner: Detective skills ensure CDI results

By Drew Siegel, MD, CCDS
One of the more interesting aspects of CDI is taking on the role of a detective to identify and evaluate clues in the medical record that suggest the presence of an undocumented diagnosis, then using these clues to write a compliant and clinically-supported query. In many cases, these clues are obvious, but the more challenging cases contain clues that require additional interpretation. Let’s look at a few of the more interesting and often undocumented diagnoses and find the diagnostic clues to form a compliant query.