Q: I work in a large, provider-based orthopedic clinic with a rheumatology department that has many patients who are very ill with several comorbid conditions. Does the physician need to document every comorbid condition that impacts his or her medical decision making for each encounter?...Read More »
Q: Although I understand that a coder cannot code from a previous encounter’s documentation, can the CDI specialist bring information to the physician’s attention such as laboratory results in order to obtain a baseline for renal failure/chronic kidney disease (CKD)?Read More »
As you put the final touches on your itinerary, we’re continuing to preview some of speakers to give you a feel for this year’s sessions. This week, we spoke with Kelli A. Estes, RN, CCDS, who, along with Cesar M. Limjoco, MD, will present, “Go After the Truth,...Read More »
Q: Should I query for chronic respiratory failure if the documentation indicates the patient has sleep apnea and is being treated with continuous positive airway pressure (CPAP) at night?
A: I love where you are going with this question, it demonstrates your critical...Read More »
As we head in to the final few weeks before the conference begins, we’re continuing to preview some of our speakers, to help you get a feel for the sessions we’ll be offering and put the final touches on your itinerary. This week, we spoke with Karen Chase, RNC, BSN, CCDS,...Read More »
Q: The primary physician documented subacute cerebral infarction and I am wondering whether I should code this to a new cerebral vascular accident (CVA) or not since the term “subacute” doesn’t really fall anywhere.Read More »
Q: When atelectasis is noted on an ancillary test such as a CT-scan of the abdomen or chest x-ray, can nursing documentation of turning, coughing, and deep breathing be considered an intervention that qualifies as one of the criteria to meet a secondary diagnosis?Read More »
The annual conference is just 34 days away. But don’t panic. We’re here to help you plan your schedule. As the countdown continues, we’ve spoken with Kyra Brown, RHIA, CCS, for a preview of her presentation “Coding of Complications: Past, Present, and Future.”
