The question often surfaces regarding what to do with CDI queries once they have been issued. My best advice is keep them. Most facilities do not consider concurrent queries part of the permanent medical record because physicians respond...Read More »
By Cheryl Ericson, RN, MS, CCDS, CDIP, and Cathy Farraher, RN, MBA, CCM, CCDS
Without a team that is fully engaged, it is impossible to maintain a compliant organization in terms of documentation. As time passes and clinical teams become more accustomed to, and comfortable with,...Read More »
The first time I read “airway protection” documented in the medical record, I realized it would require a more in-depth record review and research because airway protection by itself is not a diagnosis. It does, however, imply potential or impending...Read More »
At the time of the 2017 Physician Queries Benchmarking Survey, 48.75% of respondents conducted retrospective, pre-bill reviews and 14.96% conducted post-bill reviews. While this data is only a year and a half old, we know that things sometimes move quickly in CDI.Read More »
Q: I have a general question about how providers should list their primary and secondary diagnosis in their daily progress notes. I was taught the primary diagnosis should be listed as number 1 (first listed diagnosis) and then the other...Read More »
Ever wonder how your CDI program ranks in terms of physician query responses? Wondering if your facility is the only one that struggles to reduce the number of doctors who habitually answer “unable to determine” as a means to bypass supporting CDI?Read More »
