In the beginning, when placing queries for the type of heart failure or urosepsis, you may think that physicians will eventually learn the more specific documentation required and that your queries will no longer be necessary. I...Read More »
Q: I was told that a multiple choice query should have at least four options. Keeping in mind that there may be only one reasonable option in a multiple choice query, what would be a good fourth option for a query about hyperkalemia if the other options are:
"[Recovery Auditors] are doing a really good job at identifying the patients who don't have sepsis, and they're taking the money back," says ACDIS Advisory Board member Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.
Q:When atelectasis is noted on an ancillary test such as a CT-scan of the abdomen or chest x-ray can nursing documentation of turning, coughing, and deep breathing considered an intervention that qualifies as one of the criteria to meet a secondary diagnosis?...Read More »
Coders and clinicians seem to speak different languages. CDI specialists often serve as the translators between clinicians and coders, so it's important that all three groups work together.
Both coders and CDI specialists can query physicians when documentation:
by Wendy Whittington, MD, MMM
Physicians are grappling with understanding what all of the changes in healthcare mean for their patients and themselves, and CDI efforts are part of that equation.
I am privileged to be part of the faculty group that teaches physicians in the...Read More »
by Glenn Krauss, BBA, RHIA, CCS,CCS-P, CPUR, FCS, PCS, C-CDIS, CCDS The No. 1 struggle most CDI specialists face is getting physicians engaged in CDI, to provide accurate, specific, consistent documentation in the record. Unfortunately, unless healthcare is reformed to the point...Read More »
Q: An intoxicated patient comes into the emergency department with a history of alcoholism and the physician prescribes precautions for withdrawal and documents “tremors.” Can we assume that the physician means “delerium tremors” or “DTs”?
