Documentation Tip Card: General Documentation …
Documentation Tip Card: General Documentation Tips ... tate to contact the facility Clinical Documentation Improvement Specialist at the phone or email below.
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CDI “GOLDEN RULES”
acdis.orgCDI “GOLDEN RULES” Please write legibly (unusable by anyone for anything if illegible!!) Please use the “problem specific” approach for all charting
Outpatient Clinical Documentation Improvement (CDI): An ...
acdis.orgOutpatient Clinical Documentation Improvement (CDI): An Introduction MA paid under Medicare Part C and the impact of quality of care measures, out- patient payment represents a …
The “art” Clinical Validation - ACDIS
acdis.orgThe “art” Clinical Validation LAURIE L. PRESCOTT RN, MSN, CCDS, CDIP ... What is Clinical Validation? ... International Guide-lines for management of severe sepsis and septic shock, 2012. Critical Care Medicine 2013;41:580-637. Example of Clinical Indicators Sepsis
ACDIS position paper Defining the CDI specialist’s roles ...
acdis.org» Act as a consultant to coding professionals when addi-tional information or documentation is needed to assign coded data. » Collaborate with HIM/coding professionals to review individual problematic cases and ensure accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisors.
Clinical and Coding Conundrums - ACDIS
acdis.orgPre‐op evaluation is notable for mild, stable dyspnea on exertion. 02 Sat, exam, CXR, and EKG are unremarkable. Patient undergoes laparoscopic cholecystectomy and is slow to awaken from anesthesia. After two hours his sats remain 90% on Venti ‐mask associated with lethargy. The surgeon admits him to
Drug Induced Delirium versus Toxic Encephalopathy ACDIS ...
acdis.orgencephalopathy due to ciprofloxacin." –When queried, the provider confirmed that the antibiotic had been properly administered. • Answer: Yes. Since this is an adverse reaction to medication, assign –G92, Toxic encephalopathy, as the principal diagnosis. –T36.8X5A, Adverse effect of other systemic antibiotics, initial
and Coding of Complications
acdis.org• Atelectasis may exist preop in morbidly obese patients (obesity hypoventilation syndrome) or patients with obstructive airway disease (bronchiectasis, cystic fibrosis) or other obstruction (malignancy, foreign body, stricture) • All patients after major chest surgery may have atelectasis seen
Hypercoagulable states - ACDIS
acdis.orgApr 25, 2019 · arrhythmia, leading to a prothrombotic or hypercoagulable state. Consideration must be given to the patient's age, the presence of structural heart disease, and clinical risk factors such as previous hypertension, diabetes, various biomarkers, or heart failure (particularly depressed left ventricular systolic function).
Physician Education in Clinical Documentation Improvement
acdis.org1. Valid DRG Diagnosis is the foundation of further evaluation, treatment, appropriate disposition, and accurate coding. 2. Diagnosis must be reflective of, and consistent with, established clinical criteria 3. Listing of symptoms is not a substitute for a valid DRG diagnosis. 4. Goal is for clinical documentation to accurately reflect clinical ...
HOW PHYSICIAN ADVISORS HAVE BECOME INDISPENSABLE
acdis.orgPhysician advisors are becoming more autonomous, collaborative, and strategic as their reach expands further inside healthcare systems, touching everything from CDI and utilization management (UM)/utilization review (UR) to quality, denials management, and finance.
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