Q:If the patient comes in with a high blood alcohol level and the provider documents that number in their note, do they also need to specifically write “patient with intoxication?”Read More »
By Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS
It’s that time of year again: I am perusing proposed rules, which always hold a few interesting potential changes for the upcoming fiscal year. However, as I read the proposed rule for the 2019 Medicare Physician Fee...Read More »
There are a number of etiologies leading to pediatric respiratory failure, just as there are with adult patients. To begin with, pediatric patients can come to an acquired extrathoracic airway from an infectious source (e.g., retropharyngeal abscesses, Ludwig’s angina, bacterial tracheitis,...Read More »
Q: I need some help understanding severity of illness (SOI) and risk of mortality (ROM) as it’s my first encounter with APR-DRG factors that may affect reimbursement. First, how does one measure the SOI and ROM? Could you elaborate on how complications or comorbidities (CC) and major CCs...Read More »
By Cesar M. Limjoco, MD
Many CDI and coding professionals continue to be confused about the proper selection of principal diagnosis (PDX) for an inpatient encounter. Back in 2001, I wrote “The Principles of Inpatient Coding: Principal Diagnosis (PDX) and Other Diagnosis (ODX),.”...Read More »
Q: I have a number of questions related to strokes, but essentially, can you describe the clinical definitions of stroke and explain what CDI professionals should be looking for in the medical record?Read More »
