Have you seen reluctance in physicians wanting to respond to queries related to outcome measures? Certain practitioners seem to avoid mentioning possible severe sepsis, septic shock, and congestive heart failure (CHF) exacerbation to improve specific mortality and readmission numbers.Read More »
Recently, the patient had a two-day length of stay (LOS) on telemetry, no cardiac related symptoms or complaints, no EKG, no troponins, no cardiology consult or cardiac work-up. The patient was continued on his home medications, which included Atorvastatin and Ticagrelor. I’ve read the Official...Read More »
If a patient is admitted with a gastrointestinal bleed (self-limiting, no treatment/procedures performed or medication changes) within four weeks of the myocardial infarction (MI), would a code from category I21, Acute MI, be coded?Read More »
I’m having trouble determining how I would code an acute myocardial infarction (MI) for subsequent admissions occurring within four weeks of the initial MI. Can you walk me through the process?Read More »
Is it appropriate to routinely query cardiothoracic surgeons for ventricular fibrillation experienced by patients immediately after cardiopulmonary bypass (CPB) for open heart procedures? Our centers performing this type of surgery are hoping to identify ventricular fibrillation (V-fib)...Read More »
The Kidney Disease Improving Global Outcomes (KDIGO) criteria defines acute kidney injury (AKI) as any of the following: “Increased creatinine level greater than or equal to 1.5 times the baseline (historical or measured), which is known or presumed to have occurred within the prior seven days...Read More »
Q: We recently had a situation where a CDI reviewer sent a multiple-choice query and the physician responded and agreed that the diagnosis documented within the record was accurate. Upon audit, however, we found that the multiple-choice query sent by the CDI specialist was noncompliant...Read More »
I am getting mixed information regarding uncertain diagnoses and if they have to be documented at the time of discharge (and if so, what does the “time of discharge” mean), or if the uncertain diagnoses have to be in the discharge summary. Can you please help clarify?Read More »
