CDI departments are focusing on pediatric populations through various unique initiatives, particularly with the intent to establish organizational definitions for certain diagnoses and expand clinical knowledge of intensive neonatal care. Such initiatives can support the clinical validation of reported codes and encourage good relationships with providers in case queries are needed.
Our experts answer questions on better coding and CDI collaboration for escalation processes and AI implementation, queries for undocumented diagnoses and cause-and-effect relationships, and codes for hemorrhages as surgical complications.
Q: When a diagnosis is clinically evident but not yet documented or there is uncertainty about a cause-and-effect relationship between related conditions, would queries be outlined similarly to other types of queries or include different information?
Joanne Chopak-Foss, PhD , and Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM , look to prove how CDI professionals and coders can fully realize the value of SDOH documentation and coding in maternal and child health and shift the narrative toward equitable care for new and expecting mothers.
Q: Are there solutions for having better coding and CDI collaboration? How might this help teams with escalation processes and implementation of AI programs?
Differentiating between acute kidney injury and acute tubular necrosis is particularly critical due to their implications on medical complexity and coding classification, so Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , explores the clinical foundation and diagnostic criteria of AKI and ATN, emphasizing their distinctions and significance for clinical documentation integrity and accurate ICD-10-CM coding.
Using her own CDI team as a case study, Yohan O. Paredes, MD, CCDS , shows how the implementation of structured CDI initiatives in pediatric and OB/GYN settings can optimize coding accuracy, regulatory compliance, and financial performance.
Excluding skin cancer, breast cancer and prostate cancer are the most frequently diagnosed cancers among women and men, respectively. While both diseases originate in gender-specific organs and can range from slow-growing to aggressive forms, their clinical presentation and diagnostic complexity differ—differences that are reflected in how they are medically coded. Note : To access this free article, make sure you first register if you do not have a paid subscription.
Our experts answer questions on organizing clinical validation queries, the difficulty of diagnosing skin failures, and establishing an organizational definition of sepsis.
Differentiating between acute kidney injury and acute tubular necrosis is particularly critical due to their implications on medical complexity and coding classification, so Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP , explores the clinical foundation and diagnostic criteria of AKI and ATN, emphasizing their distinctions and significance for clinical documentation integrity and accurate ICD-10-CM coding.
ICD-10-CM codes for Parkinson’s disease differ based on the primary neurologic diagnosis and any complications or comorbidities involved, as PD can manifest in various forms, each with unique characteristics.
Social issues often get left out of the conversation when providers, caregivers, and patients are busy, stressed, and focused on the immediate problem that occasioned a visit or admission; however, Nicole Nodal-Rodriguez, MSN, RN, CCDS , considers how having SDOH carried through the record can have a trickledown effect on treatment plans, identification of health disparities, and community services.
Our experts answer questions on the role of prior encounters in queries, coding neoplasms in transplanted organs, and workflows for reporting malnutrition and pathology.
Psychosis often emerges or is managed in outpatient mental health settings, but it can be coded during inpatient hospital stays due to the acute nature of the condition when it reaches a crisis point. To ensure that this mental health diagnosis receives the same diligence as medical and surgical diagnoses, Nancy Reading, RN, BS, CPC, CPC-P, CPC-I , provides coders with guidance on finding the right codes and resolving documentation conundrums.
Catherine O’Leary, RN, BSN, CCDS , suggests that those who begin with manual coding and DRGs often develop a stronger, more intuitive foundation in CDI and how integrating manual training into a modern CDI program doesn’t mean abandoning technology. Her insights may prove valuable to coders who may increasingly find themselves working at the intersection of coding and CDI.
Jenny Esper, RHIA, CDIP, CCS, CCDS , and Lizabeth Volansky, BSN, RN, CCDS, RHIA, CDIP, CCS , explore the topic of including references or links to definitions within query notes and how such a practice can enhance documentation and coding.
