This sample was reviewed and approved by the ACDIS Resource Library Committee in 2023. The committee noted that if you use this resource, it requires a space to index clinical indicators, and the resource must be rid of all bold and underlined phrases, as these are considered leading queries...
This ICD-10 cerebral artery infarction progress note is courtesy of Fran Toleno, RHIT, CCS, CDI coordinator and coding reimbursement specialist in the HIM department at Winthrop University Hospital in Mineola, NY. It was published in the February 2012 issue of Medical Records Briefing...
Signs or symptoms of an underlying condition should be coded only if the physician can not determine a definitive diagnosis. When the physician simply neglects or forgets to document the diagnosis, CDI staff can use this sample query template provided by Alesha Andrews, RHIT, CCS, and Adam...
