Q:Our program does not typically include query information as part of the medical record. If the physician responds to a faxed query, we scan the fax into our electronic record. However, we resolve most queries in person or through a secure messaging system in our EMR (...Read More »
Q:I have heard that some facilities have seen their number of generated queries actually increasing rather than decreasing over time. Generally, we hope that by improving the documentation concurrently, we would decrease the need to ask the questions retrospectively. If...Read More »
Prior to implementing an electronic query application from Meta Health Technology in 2010, the query process at Memorial Hermann was completely manual and extremely time-consuming. To submit a post-discharge query, the coder created a Word document...Read More »
Operative reports can be a gold mine of information, far surpassing often vague or generalized progress notes, but sometimes this resource is left completely untapped, says Lynne Spryszak, RN,CPC-A, CCDS. Coders know they should review the complete operative report before coding...Read More »
Q: Is systemic inflammatory response syndrome (SIRS) an inherent part of an infection? For example, when a patient comes in with pneumonia, and clinical indicators are present for SIRS but the physician did not specifically write SIRS, should coders or CDI specialists query physicians?...Read More »
Q:A patient is admitted with an elective colon resection. The physician documents postoperative ileus but then on the day of discharge the notes states: expected postoperative ileus. So do we add the code 997.4 or not?
Q: We had a patient come in for back pain and treatment for a possible neurological impingement. However, after a five-day stay, the physician documents neck mass and for the remainder of the stay the resources appear to have been focused on that treatment. How do I discern the principal...Read More »
