Editor’s Note: AHA Coding Clinic for ICD-9-CM released its second round of ICD-10 coding guidance in its First Quarter 2013 issue. HCPro CDI Education Director Cheryl Ericson, MS, RN, CCDS, CDIP, says the guidance contains information regarding diagnosis clarification,...Read More »
Q:I realize that if the body mass index (BMI) of a patient is documented by nurses and dieticians 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...Read More »
Have you ever read a history and physical (H&P) report and wondered why the patient was admitted? Have you ever wondered which diagnoses were resolved prior to admission?
If you are a CDI specialist or coder you’ve probably struggled...Read More »
In my senior year of college the physician teaching our pathophysiology class gave the following assignment: “Define acute renal failure (ARF), based on signs, symptoms, lab findings, and cite abnormal laboratory values.”
