Our providers tend to use the term “RDS” in their documentation to describe all “respiratory distress,” “respiratory distress syndrome of newborn...Read More »
According to our software vendor, you can only code liver lacerations as minor, moderate, or major. According to all the educational materials I...Read More »
What are the requirements when it comes to a physician advisor asking for diagnoses to be added to the medical record? Based on the ACDIS/AHIMA “...Read More »
Our query process currently creates a physician progress note when a query is answered which becomes part of the permanent medical record. We do...Read More »
I believe there was a Coding Clinic several years ago where the diagnosis of “mental incompetence” was changed to “intellectual disability,” but I...Read More »
How can real-time chat function in an electronic health record (EHR) be used? Are CDI specialists and physicians receptive to a real-time chat?Read More »
Recently, we’ve seen an uptick in clinical validation denials regarding acute pulmonary insufficiency and acute respiratory failure following...Read More »
Are institutions appealing sepsis denials if the patient meets sepsis-2/super systemic inflammatory response syndrome (SIRS) criteria, but not...Read More »