Q: What terms need to be included in physician documentation to code in ICD-10-CM whether the patient’s migraine is chronic, intractable, or with status migrainosus?
A: “The patient has a migraine,” is insufficient documentation. Let’s...Read More »
Tracy Gapinski, BSN, RN, CCDS, is a CDI specialist lead at Community Healthcare System in Valparaiso, Indiana, and is associated with the Indiana ACDIS chapter. She has been in the CDI field for six years now.
ACDIS: What did you do before entering CDI? ...Read More »
Q: I have a couple of questions regarding CDI metric expectations, reporting, and education for your CDI teams. I have been working on a CDI metrics report of the expected systemwide versus individual query rate, review rate, physician response rate, agreement rate, and expected...Read More »
Q: Are you using contingency staffing in your inpatient programs? If so, do you require any pre-testing to evaluate competency? What has you experience been with using these temporary workers?
Response #1: We currently have more than 10...Read More »
Kerri Swart, BSN, RN, CCRN-K, CCDS, is the CDI director at Upstate University Health System and is associated with the ACDIS Central New York local chapter. She has been in the CDI field for four and a half years.Read More »
Q: What is the pathway for mortality cases at your organization? We review the mortality cases that have a risk of mortality (ROM) and severity of illness score of 4 or below, and to improve the observed to expected ratio (O:E). The workflow, however, is inefficient, and the CDI team...Read More »
Q: I’ve heard some facilities are beginning to incorporate ICD-11, even though it is not yet implemented in the United States. How can coders help their providers transition to ICD-11?Read More »
Q: Does anyone have any proposal examples of inpatient CDI team expansion they'd be willing to share? I am working on putting one together, but it would be very helpful to see other leaders’ successful proposals. To further clarify, what we are trying to do is basically justify the...Read More »