Q:When atelectasis is noted on an ancillary test such as a CT-scan of the abdomen or chest x-ray can nursing documentation of turning, coughing, and deep breathing considered an intervention that qualifies as one of the criteria to meet a secondary diagnosis?...Read More »
Striving for the correct DRG assignment on the first pass should be every coder’s goal. This is not simple, and a close look reveals that the complexity of coding rules and the quality of documentation in facilities sometimes make...Read More »
$500,000. That’s what facilities expect as their CDI programs’ annual return on investment (ROI), according to 58% of more than 1,660 respondents to a recent ACDIS website poll (www.hcpro.com/acdis/readerpoll_results.cfm). When...Read More »
When I started learning how to be an educator, I quickly learned the saying “seven times, seven ways.” The idea being we need to hear information repeatedly and receive it in a variety of ways before we are able to learn and...Read More »
A large number of hospitals across the country have some version of a CDI program in place. With ICD-10 implementation on our heels, it is recommended by AHIMA that all hospitals have a “mature” CDI program in place by October 1, 2014.
Q:Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase “versus” between them? For example, the patient arrives with abdominal pain and the physician orders labs and other tests but they all come back normal. In the discharge note, the...Read More »
