Q: I realize that if the body mass index (BMI) of a patient is documented by nurses and dieticians, it can be coded if the physician documents the clinical significance (i.e., morbid obesity). However, if the BMI is documented by a patient care tech or nursing ward secretary in...Read More »
More than 1,000 CDI professionals now hold the Certified Clinical Documentation Specialist (CCDS) certification. ACDIS publishes the list of those who earned their certification on a quarterly basis. The latest list is available on the “...Read More »
Here is a statistic that will come as no surprise to most coders and CDI professionals: Approximately 50% of physicians, physician assistants, and nurse practitioners have no clue about ICD-10.Read More »
Q: The physician documented mild bronchitis treated with Zithromax in the progress note on day two of the patient’s hospital. I looked for clinical indicators and the only documentation I found in the nursing notes was that the patient had a non-productive cough on admission. ...Read More »
