Recently, the patient had a two-day length of stay (LOS) on telemetry, no cardiac related symptoms or complaints, no EKG, no troponins, no...Read More »
If a patient is admitted with a gastrointestinal bleed (self-limiting, no treatment/procedures performed or medication changes) within four weeks...Read More »
Wrestling with bandwidth challenges, a large physician group in the Midwest struggled with making changes to status quo documentation and coding practices. While documentation and coding improvements were acknowledged as critical success factors, options for making such improvements without...
I’m having trouble determining how I would code an acute myocardial infarction (MI) for subsequent admissions occurring within four weeks of the...Read More »
Each stage of the CDI documentation integrity process represents an opportunity for additional leakage of accurate and appropriate documentation, resulting in inaccurate coding of conditions being monitored and treated during the patient's encounter. This results in inappropriate reimbursement...
This sample CDI specialist qualitative assessment was provided by Deanne Wilk, BSN, RN, CCDS, CCS, CDI manager at Penn State Health in Hershey, Pennsylvania.
