Q:What information do you have about physician response to ICD-10-PCS? I am getting some push-back from surgeons. The response I received from a surgeon was, “I want to choose my own words for the surgery that I performed” and “I don’t want a coder picking the words, ‘removal or...Read More »
Q: When did the CDI program at Wake Forest University Baptist Medical Center start getting involved in looking at quality-related documentation concerns and what was the impetus for the evolution?
A: It started with pressure ulcers. Back in 2011/2012 the...Read More »
Q: Should “diabetes with gastroparesis” be coded as 536.3, diabetes with a complication code? I understood that the term ‘with’ can link two diagnoses, but that it does not represent a cause-and-effect relationship. Can you please clarify this, and why a cause-and-effect relationship can...Read More »
This week, we spoke with conference committee member, Rita Fields, RN, BSN, clinical documentation specialist at Baptist Hospital East in Louisville, KY, about her experiences serving on the committee, and what she’s looking forward to at the 2016 conference.
Q: Do you have any advice or guidance on how to conduct chart reviews for beginners in CDI? I am looking for specific strategies and approaches that might help our program, such as viewing labs first, or looking at emergency room (ER) notes, or history and physical notes (H&P)?Read More »
Q: Is the statement “please document in a progress note to capture the severity of illness (SOI), risk of mortality (ROM) and care needed for this patient” appropriate to use in a query? In general, is it appropriate to mention SOI/ROM and support level of care and profiling when querying...Read More »
