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...Read More »
Q: We’re having a lot of discussions with physicians right now and need to get some clarity on acute cor pulmonale versus chronic. Do you have any insight on that differentiation between the two with right-sided heart failure, chronic obstructive pulmonary disease (COPD), shortness of...Read More »
Q: If a patient has hypertensive heart disease or cerebrovascular accident (CVA) with hemiparesis in his or her past medical history which has not been brought forward in the patient’s medical record for their current inpatient stay, can the coders assign a code for that...Read More »
We’re less than six weeks away from our annual conference! As the countdown continues, we’re previewing a handful of speakers to give you a feel for the educational sessions being offered. This week, we spoke with Lynn H. Lowery, CPC, CFPC, who, along with Trey A. La...Read More »
Q: How would the following be viewed if it was included in a cardiology consult note:
“Mr. X has paroxysmal atrial fibrillation. He had a recurrence last night which was asymptomatic. We think this happens all the time at home. This is not a pacing...Read More »
Q:In my facility, we are supposed to send an e-mail to our physician advisor (PA) and to administration if a query is not answered within a week. However, this policy doesn’t work well because administration does not do anything with that information, and the PA doesn’t...Read More »
Q: Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase “versus” between them? For example, the patient arrives with abdominal pain and the physician orders labs and other tests but they all come back normal. In the discharge note, the physician documents “...Read More »
