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Q: What is the best way to document time spent by physicians performing procedures? The CPT® codes state a vague time amount but the...Read More »

Q: I am having difficulty understanding “late effects.” The statement of a “condition or nature of the late effect is sequenced first,”...Read More »

Q: If the patient is a Medicare beneficiary, why wouldn’t a MS-DRG associated with the newborns and other neonates major diagnostic...Read More »

Q: Some CDI specialists tell physicians not to document acute renal insufficiency because it does not code to acute renal failure and I am...Read More »

Editor’s note: William Haik, MD, FCCP, CDIP, director of DRG Review, Inc. answered the following questions in...Read More »

Editor’s note: Nicole F. Draper, RN, BN, MHA, DH-C, is the manager of length of stay, documentation, and revenue optimization...Read More »

Editor’s note: Cheryl Ericson, MS, RN, CCDS, CDIP, is the manager of clinical...Read More »

Editor’s note: Cesar M. Limjoco, MD, and Kelli A. Estes, RN, CCDS, will...Read More »

Q: Does sepsis and/or severe sepsis have to be documented in the medical record when only septic shock is noted? We have a couple of...Read More »