Q:I realize that if the body mass index (BMI) of a patient is documented by nurses and dieticians can be coded if the physician documents the clinical significance (i.e. morbid obesity). However, if the BMI is documented by a patient care tech or nursing ward secretary...Read More »
Q: I was interested in further discussion about cystic fibrosis coding. I am conducting an audit on MS-DRGs 177, 178, and 179, Respiration infections and inflammation with MCC, CC, and without CC...Read More »
Q: If a hospital CEO were to tell a new CDI department manager to pull together some statistics on the performance of the department, where should he or she begin?
We recently had a case where a patient with severe chronic obstructive pulmonary disease (COPD) was admitted for several lung lesions. The patient went to surgery for de-cortication of lung due to left lung entrapment with adhesions, deep wedge resection of mass of the upper lung and left lower...Read More »
Our hospital serves a higher than usual population with COPD. Most of these cases are chronic and the patient is typically on home oxygen. Blood gases are almost never obtained on admission unless the patient is placed on a ventilator. Is acceptable to query the physician for chronic respiratory...Read More »
