This is a classic documentation opportunity to clarify “volume/fluid overload,” says Lynne Spryszak, RN, CPC-A, CCDS, CDI education director for...Read More »
Signs or symptoms of an underlying condition should be coded only if the physician can not determine a definitive diagnosis. When the physician simply neglects or forgets to document the diagnosis, CDI staff can use this sample query template provided by Alesha Andrews, RHIT, CCS, and Adam...
Only 1.5% of the nearly 3,000 nonfederal hospitals in the United States reported the use of a comprehensive electronic medical record (EMR) system...Read More »
It’s not enough to know whether heart failure is systolic or diastolic. Congestive heart failure (CHF), for example, isn’t an inherent component...Read More »
Congestive heart failure (CHF) is one example of a condition for which coders and CDI specialists should understand clinical indicators before...Read More »
Despite some misconceptions to the contrary, a coder may report angina, unstable (411.1) if a physician documents any of the following diagnoses...Read More »
Many CDI specialists struggle with the problem of educating physicians about documentation requirements. Typical trouble areas include acute...Read More »
Recent CDI-related headlines include concerns about the burden of paperwork on patient care and the cost of healthcare. And article authors cite...Read More »
