Coronaviruses are a large family of viruses that cause illnesses ranging from the common cold to more severe diseases such as Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS). The SARS-CoV-2 coronavirus, which had not previously been identified in humans, is the strain that was discovered in 2019. It causes novel coronavirus disease (COVID-19) and is responsible for the current global pandemic.
Physicians can be a bit prickly at times. While this statement intentionally downplays the behavior of (hopefully) only a few doctors, I believe that most physicians are amenable to CDI concepts. While attempting to effect change in physician documentation patterns, I’ve learned many lessons from my medical staff and from other creative CDI colleagues.
To deal with the rising rate of infection and increased hospital admissions for extraordinarily sick patients due to the novel coronavirus (COVID-19), CDI teams have had to act quickly by adapting to remote work, modifying CDI practices, and more.
Joel Moorhead, MD, PhD, CPC , writes that certain clinical indicators provide strong support for a diagnosis of acute-on-chronic congestive heart failure (CHF) in adults. Because of this, it’s important for inpatient coders to familiarize themselves with baselines and clinical indicators in order to ensure accurate reporting.
Cheryl Manchenton, RN, BSN, CCDS, CPHM, writes that when it comes it reporting novel coronavirus (COVID-19), our understanding of it and its sequelae/manifestations is continually evolving. There is one “manifestation” of COVID-19 that is of interest for experimental treatment: cytokines.
It’s been nearly three years since HCPro’s last survey dedicated to query practices . Since querying is a constant and continuous aspect of CDI work, a 16-question survey focused on physician queries was recently conducted. Because of the survey’s limited length, it concentrated primarily on productivity and compliance concerns.
Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC , gives guidance to CDI teams working on clinical validation, denials prevention, and appeals processes to help ensure proper reimbursement for their hospitals.
Laurie L. Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , reviews Coding Clinic , First Quarter 2020, guidance, which includes topics such as reporting vaping-related disorders, malnutrition, and bariatric procedures.
Sarah A. Nehring, CCS, CCDS, writes that an inpatient coder’s first concern regarding the reporting of novel coronavirus (COVID-19) is to code all confirmed cases and only confirmed cases. In this article, Nehring details guidelines on how to accomplish this.
Clinical validation reviews and queries ensure that the documented diagnoses and clinical indicators hold up to inspection. This article gives an overview on processes and templates, top queried diagnoses, and physician engagement to help CDI teams perfect their clinical validation efforts.
