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CDI Training: Documentation and coding requirements regarding complications

The attached Word document reviews documentation and coding needs for complications and establishes policies and procedures for coders and CDI professionals to follow. Created by Paul Evans, RHIA, CCS, CCS-P, CCDS, the document provides complication definitations, explains when queries should be issued, and explores specific documentation concerns regarding coditions such as Incidental Serosal Tear and postoperative atrial fibrillation.

See also coding complications training PowerPoint presentation in the Education & Training section of the Forms & Tools Library.

 

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