If a coder reviews the chart of a patient in the emergency department (ED) or intensive care unit with documented symptoms, such as fever (or low temperature), elevated white cell count (or low white cell count), altered mental status, evidence of an...Read More »
Q: AHIMA’s 2008 practice brief, “Managing an Effective Query Process,” appears to allow the initiation of post-bill queries as a result of an audit or other internal monitor. Historically we believed that a query completed after the initial bill was not permitted to be submitted for...Read More »
“If you’ve ever read a document that contained convoluted language or gibberish jargon, read on,” a press release from The Center for Plain Language stated. I received that release more than a...Read More »
by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS
While riding the gondola at Snowbasin ski area last week in Utah, I had the opportunity to converse with a physician (who happened to be riding up the lift with me) regarding the field of CDI. His interpretation of CDI centered...Read More »
Q:I am looking for help posing queries regarding the specific link between diabetes and conditions typically considered diabetic complications. Should we always query the physician regarding the link between the presenting symptom and the diabetes?
We, in the United States, will soon need to adopt the electronic health record (EHR). Over the past few years, of course, healthcare entities have slowly converted from the traditional handwritten medical record toward one that is totally digital. There have...Read More »
Q:I know that in an inpatient setting coders are allowed to use a suspected diagnosis when a definitive diagnosis cannot be determined. However, we have had some trouble with physicians using the term “rule out” or “differential diagnosis” when it comes to a recovery...Read More »
I challenge you to find one textbook of medicine, physiology, or pathology that refers to a category of hematologic abnormality as “acute blood loss anemia.”
But coders are very familiar with that term. They may ask a physician whether a...Read More »
