Q: I had a recent case where the nephrologist and cardiologist both documented hypertensive (HTN) emergency, but the attending documented HTN urgency. The attending was correct based on clinical indicators. Does that mean I don't have to query the attending and can just take...Read More »
Is there a list or guidelines for what terminology is considered adequate to establish a link between two conditions, similar to the uncertain diagnosis list?
Would the example above of “GI bleed in the setting of anticoagulants” be sufficient
I am wondering why it is recommended to bring a DRG code book when taking the ACDIS CCDS certification exam? Most CDI programs use online software, and many teams are remote now. Are programs buying code books for their staff?Read More »
Our care coordination team has typically handled our Program for Evaluating Payment Patterns Electronic Report (PEPPER) analysis, but the department head doesn’t feel comfortable in reporting and discussing outliers other than readmissions. Can you offer any assistance into what CDI programs...Read More »
We do many queries for malnutrition and are looking for a better way to get this essential diagnosis into the medical record without a query. I understand that some organizations have the dietitian document it and the provider attest to the diagnosis. Is that acceptable practice? Our thought is...Read More »
