Q: If the patient is a Medicare beneficiary, why wouldn’t a MS-DRG associated with the newborns and other neonates major diagnostic category (MDC) not be used? Is it because the patient is more than likely 65 (since they are a Medicare beneficiary) and this MS-DRG is for a newborn/...Read More »
Q: Some CDI specialists tell physicians not to document acute renal insufficiency because it does not code to acute renal failure and I am wondering if that is considered appropriate.
For instance, I was reviewing a chart and the physician documented that the...Read More »
Editor’s note: Nicole F. Draper, RN, BN, MHA, DH-C, is the manager of length of stay, documentation, and revenue optimization at St. Vincent’s Private Hospital Sydney in Darlinghurst, New South Wales, Australia. She presents “Measuring clinician engagement: The journey to...Read More »
Editor’s note: Cheryl Ericson, MS, RN, CCDS, CDIP, is the manager of clinical documentation services at DHG Healthcare in Charleston, South Carolina. She is a CDI subject matter expert for a variety of industry publications and keeps...Read More »
Editor’s note: Cesar M. Limjoco, MD, and Kelli A. Estes, RN, CCDS, will be presenting “The ultimate test for queries,” on Day 1 of the ACDIS conference. Limjoco is the vice president of DCBA, Inc. in Indianapolis, Indiana....Read More »
Q: Does sepsis and/or severe sepsis have to be documented in the medical record when only septic shock is noted? We have a couple of physicians that will document septic shock without noting sepsis and/or severe sepsis. I was informed that coding needs to also have the documentation of...Read More »
