Q:I was wondering what supporting evidence there is for the recommendation to go ahead and link hypertension (HTN) with heart failure as a combination code? The Official Guideline for Coding and Reporting as well as Coding Clinic for ICD-9-CM seems to...Read More »
Q: A consultant has advised us to code only diagnoses listed on the discharge summary. If the diagnosis is not on the discharge summary, the consultant instructed us to query the physician. How do other facilities handle these scenarios?
Q:Our program does not typically include query information as part of the medical record. If the physician responds to a faxed query, we scan the fax into our electronic record. However, we resolve most queries in person or through a secure messaging system in our EMR (...Read More »
Q:I have heard that some facilities have seen their number of generated queries actually increasing rather than decreasing over time. Generally, we hope that by improving the documentation concurrently, we would decrease the need to ask the questions retrospectively. If...Read More »
Q: Recently, a consultant suggested that if we asked the physician to clarify systolic/diastolic on a query form for congestive heart failure (CHF) it might be construed as leading the physician if there had been no previous mention of...Read More »
Q: Whenever we get a trauma patient, it’s either very easy to get to the multiple significant trauma (MST) major diagnostic category (MDC), or it becomes a real challenge, especially taking into account the rules pertaining to two body sites...Read More »
Q: Our CDI specialists call the physicians when queries have not been answered. Sometimes the physician will give us an answer over the phone. I’m wondering if that’s okay. Can our CDI staff, who are registered nurses, take the verbal...Read More »
