By Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC
One pitfall many CDI professionals face is one I faced myself in my early years. As a young CDI professional, I stressed to everyone, “I am not a coder.”
I still say that to people who ask me very specific questions related to...Read More »
“DRG validation can mean many things in many different arenas,” Autumn Reiter, RN, BSN, CCDS, CDIP, CCS, director of CDI staffing services at TrustHCS, said on the January 3 episode of ACDIS Radio, “New approaches in DRG validation.” “Essentially, it’s ensuring a correct final...Read More »
Q: According to Official Guidelines for Coding and Reporting, uncertain diagnoses should be documented at the time of discharge. If a consultant documents an uncertain diagnosis in the final or last progress note and no discharge...Read More »
Jose M. Gonzalez O’Neill, MSHIM, RHIA, is the vice president of the Florida ACDIS chapter, and HIM service line manager for medical transcription and inpatient coding at a large hospital system in the Orlando area.Read More »
Sepsis’ complexity and frequent definition updates propose challenges for CDI and coding professionals but it’s also a gray area in clinical medicine.Read More »
by Paul Evans, RHIA, CCDS, CCS, CCS-P
We have seen our industry grow increasingly complicated each year. With that increased complexity, we also see greater sophistication among our colleagues’ skill levels.
CDI professionals now specialize in quality reviews for hospital–...Read More »
Q: I understand the Official Guidelines for Coding and Reporting related to pressure injuries and present on admission (POA) status. For example, I know that if a decubitus ulcer is a stage 1 on admission and progresses to stage 4 during the stay, we are to code stage 1...Read More »
By Lynelle A. Clausen, RN, BSN
I started working as a CDI specialist in May 2014, and was assigned to oncology, intensive care and the step–down unit (SDU) to complete reviews. I have a seasoned clinical background in these areas and knew what to look for in the medical record....Read More »
