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Q: We are seeing an influx of possible COVID-19 patients at our facility. How can we prepare to query for COVID-19-related documentation and...Read More »

Q: Recently, we’ve seen a few situations in which respiratory failure was present on admission (POA), but then later in the stay, the patient’s...Read More »

Q: We’re having some trouble with malnutrition documentation. In many instances, the patient meets the American Society for Parenteral and Enteral...Read More »

Q: How can we help providers understand that clinical validation queries aren’t meant to question their medical decision making? Read More »

I’ve always thought that, as long as the clinical indicators support the condition you’re querying for, providing all the options for the specific...Read More »

Q: Most of the hospitals in our system make the query a progress note in the patient’s medical record. The provider puts an “X” by the...Read More »

If a patient is admitted with both gram-negative pneumonia and acute respiratory failure, which should be sequenced as the principal diagnosis?Read More »

When can unconfirmed diagnoses be coded? Are there any exceptions to the guidelines governing code assignment?Read More »

Dawn Valdez RN, LNC, CCDS, CDIP, joined the ACDIS team officially at the beginning of 2020, as a full-time CDI education...Read More »

Q: Our organization has implemented a workflow to identify social determinants of health (SDOH). The tool is provided to patients at annual visits...Read More »