Q:I have a question about the discharge summary. When a physician documents a firm diagnosis (not probable or suspected) the day before discharge can it be coded as confirmed, or does it need to be documented on the last day/in the discharge...Read More »
Despite some misconceptions to the contrary, a coder may report angina, unstable (411.1) if a physician documents any of the following diagnoses and a query is not required:
ACDIS Associate Editorial Director Linnea Archibald sends out “missed connections” emails with questions from Council members on a regular basis. Anyone with experience related to one of the questions was invited to respond and Archibald connected them with the question-asker. In order to share...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 »
Many CDI professionals diligently perform the day-to-day tasks of documentation improvement. And there are those who carry out this duty and so much more. The 2010 CDI Professional of the Year award and the two awards for Recognition of CDI Professional Achievement honor these...Read More »
Emily Castelvecchi, MSN, MHA, RN, CCDS, CRCR,asks: “We are looking into creating separate and distinct job descriptions for CDI. One for our exempt CDI specialists who are RNs, PAs, NPs, or MDs, and one for our non-exempt CDI specialists who are coders, respiratory therapists,...Read More »
by Melissa Varnavas, CPC, ACDIS associate director
In the fall of 2009 Leah Taylor, RN, CCDS, and Jennifer Love, RN, BA, CCDS, president and vice president of the North Carolina ACDIS chapter respectively, challenged members of their local chapter to earn...Read More »
