Q: We recently had a case where the patient was admitted from the ED with pneumonia but the attending hospitalist diagnosed acute bronchitis because the chest x-ray did not show infiltrates or any of the verbiage indicating possible pneumonia.
Q: I was under the impression that headings on a query form are leading. Can you help me with this? I would use a heading but replace the (example: Acute Renal Failure) with the physician’s wording (ex: Renal insufficiency). Then paint the clinical picture with appropriate choices.Read More »
Q: Our CDI program is three years old and our administration still questions our productivity goals. Initially we set benchmarks at 90-95% coverage rate of Medicare/Managed Medicare; 20-25% query rate; 90% response rate and 80% agree rate. Since census varies, we also established goals of...Read More »
Editor’s Note: The following questions were submitted for the ACDIS quarterly conference call of February 14, 2013, and were answered by Donna Wilson, RHIA, CCS, CCDS, Robert Gold, MD, Sylvia Hoffman, RN, CCDS, CCDI, CDIP, and Donald Butler, RN, BSN, of the ACDIS...Read More »
Q: A few times I have seen physicians document Schatzki’s Ring. I understand that if the physician documents “acquired Schatzki’s Ring” that maps to code 530.3 no CC/MCC. However, how would...Read More »
Q:We recently had a case where the patient was admitted for “sepsis secondary to a urinary infection (UTI) with chronic Foley.” I am wondering if there is a AHA Coding Clinic for ICD-9-CM tosupport coding this case to 996.64, Infection and...Read More »
Q: An intoxicated patient comes into the emergency department with a history of alcoholism and the physician prescribes precautions for withdrawal and documents “tremors.” Can we assume that the physician means “delerium tremors” or “DTs”?
Q: I’ve been confused recently regarding coding from the pathology or radiology reports for specificity. It seems that in recent years, (I’ve been coding for 25years) a new interpretation of the coding guidelines has come about. I was taught that as long as a physician with direct...Read More »
