Q:I have a question about the discharge summary. When a physician documents a firm diagnosis (not probable or suspected) the day before discharge can it be coded as confirmed, or does it need to be documented on the last day/in the discharge...Read More »
ACDIS Associate Editorial Director Linnea Archibald sends out “missed connections” emails with questions from Council members on a regular basis. Anyone with experience related to one of the questions was invited to respond and Archibald connected them with the question-asker. In order to share...Read More »
Q:I am looking for help posing queries regarding the specific link between diabetes and conditions typically considered diabetic complications. Should we always query the physician regarding the link between the presenting symptom and the diabetes?
Q: Payers have been pushing back when a diagnosis appears in the discharge summary and not in the chart. Can the physician add a late entry or addendum into the medical record by way of a progress note or an addition to a discharge summary...Read More »
Q:I know that in an inpatient setting coders are allowed to use a suspected diagnosis when a definitive diagnosis cannot be determined. However, we have had some trouble with physicians using the term “rule out” or “differential diagnosis” when it comes to a recovery...Read More »
Q: Our CDI specialists tend to ask questions that provide the physician with multiple options to choose from. It is not uncommon to have a query with multiple answers checked by the physician.
