As a preview of the eleventh annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. These Q&As will continue throughout CDI Week, September 13-17 as well. Gail Weldon, RN, CCDS, CDI team lead at...Read More »
I am looking for clarification on two seemingly contradictory statements. One says when a practitioner documents a diagnosis that does not seem supported by clinical indicators a query should be raised. However, the other states that a provider's statement that a particular condition is present...Read More »
As a preview of the eleventh annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. These Q&As will continue throughout CDI Week, September 13-17 as well. Brian Simpson, MS, RRT, CCDS, CCDS-O, CDIP...Read More »
Q: If an echocardiogram shows a type of trace/mild/moderate regurgitation, is that enough to query for that diagnosis? Or is this considered an insignificant finding?Read More »
Can you please discuss right heart failure and its relationship to pulmonary hypertension instead of diastolic heart failure. For example, established diagnosis of heart failure and methamphetamine intoxication, established diagnosis of heart and smoke inhalation or carboxyhemoglobinemia, or...Read More »
When I was trained as a new CDI specialist, I was told that I could query for hyponatremia with two low sodium (NA) values as a clinical indicator as it shows that while it is not necessarily being treated, hyponatremia is being monitored.
A recent conversation with a senior CDI...Read More »
Q: When is it appropriate to code both flash or acute pulmonary edema and acute on chronic heart failure (diastolic, systolic, or other)? What other etiologies lead to flash pulmonary edema and how do I know when to query?Read More »
Our facility has adopted a systemwide definition of sepsis (based on Sepsis-3) and we’re having success with educating most providers. Some of our infectious disease providers, however, like to use the term septicemia which codes to A41.9, Sepsis, unspecified organism. This is somewhat of a...Read More »
