Q:If the provider documents: “Pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue, right elbow,” does the CDI specialist need to query for the stage? Or, will it be coded as a stage...Read More »
Stacey Nagao, BSN, RN, CCDS, will be presenting a poster at the 2018 ACDIS Conference entitled “How to write a note: Development of a resident documentation curriculum.”Read More »
Q:Recently I’ve been given the opportunity to present CDI concepts at the quarterly medical staff meetings. They have given me 10 minutes each quarter to teach a topic. I am excited, but it also feels a bit daunting. How I can...Read More »
Q:Would there be any legal or ethical issue if a CDI nurse did the discharge summery for a group of physicians and then they agree and sign off on them?Read More »
Charlene Compher, PhD, RD, LDN, FASPEN, and Richard Pinson, MD, FACP, CCS, will present “GLIM: The New Malnutrition Clinical Criteria and Implications for the CDI Profession,” on Day 1 of the ACDIS conference. Compher is a professor of nutrition science at the University of Pennsylvania School...Read More »
Q:Is it a coder’s responsibility to properly sequence secondary diagnoses or is this a process that happens when the codes are transferred to the super bill? My concern is with making sure that heavily weighted secondary...Read More »
Q:We recently had a patient who had a syncopal episode and fell, sustaining head trauma with a resultant SAH. What is the proper coding and principal diagnosis? Is this traumatic SAH with loss of consciousness or SAH with...Read More »
Bettina Sonen, RN, CCDS, is a clinical documentation educator at Northeast Georgia Health Systems (NGHS) in Gainesville, and she is a member of the Georgia ACDIS local chapter.Read More »
