by Laurie L. Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC
It’s springtime! Daffodils are sprouting, birds are nesting, and our first quarterly Coding Clinic has arrived. Generally, the first release of the year is packed full of direction, and this issue did not disappoint...Read More »
Getting clinical conditions appropriately documented is not a new problem in medicine, especially in pediatrics. This is particularly true for conditions where a universally accepted clinical definition does not exist, such as heart failure for pediatric patients. This has led individual...Read More »
A new year often spells change for CDI programs looking to extend their influence in their organizations. With the rise of health systems over independent hospitals, many CDI teams find themselves reviewing records outside of the traditional acute care...Read More »
We’re having a lot of discussions lately on whether we should query for pressure injuries when they’re only documented by nursing. Our wound care nurses determined that staff nurses identify pressure injuries correctly only 60% of the time. If we’re querying based on nursing documentation, our...Read More »
In recent years, clinical validation has become a prevalent topic in the CDI field. According to Elizabeth Aguirre, MD, CCDS, CDI program physician lead at Baylor Scott and White Medical Center in Temple, Texas, the increased focus is at least partially the result of common...Read More »
by Amy Sanderson, MD
Pulmonary hypertension (PH) is a complex, progressive disease that affects both children and adults, and leads to significant morbidity and mortality. PH has been defined as a mean pulmonary artery pressure . 25 mmHg when the patient is at rest (see references...Read More »
by Sarah Nehring, CCS, CCDS
In my experience, some of the largest disconnects between provider and coder thinking occur when it comes to neoplasm-related admissions. Consequently, it’s also where some of the greatest query frustration occurs. To help ease some of the consternation...Read More »
Charles Dickens’ novel Great Expectations is a coming-of-age story, full of lively characters and an insightful exploration of themes such as wealth and poverty, love and rejection, and the triumph of good over evil. At least that’s...Read More »
