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.
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 considered an intervention that qualifies as one of the criteria to meet a secondary diagnosis?...Read More »
Q: I had a question about whether or not queries can be used to question the documentation of a condition or procedure where the clinical picture in the record does not appear to support a given diagnosis. I thought the new ACDIS/AHIMA query practice...Read More »
Q: I have come across an ethical dilemma. We have a small CDI program and a “home grown” application we use to report metrics to the chief financial officer (CFO). In this, we track whether a CDI specialist’s query captured a CC/MCC. If it is the...Read More »
Q: During a recent ACDIS Quarterly Conference Call a coder expressed discomfort regarding a nephrologist’s diagnosis of acute renal failure that did not meet RIFLE...Read More »
