The Winthrop University Hospital clinical documentation improvement (CDI) specialists and HIM team implemented a new query for cerebral infarctions in preparation for the transition to ICD-10. The newly created form incorporates the language necessary to capture documentation within this new area of enhanced specificity.
This form includes a clarification request for respiratory failure, including sourced definitions. It is intended as a sample only and any diagnostic criteria should meet the approval of your medical staff.
ICD-10-CM and ICD-10-PCS should eventually result in better data capture nationwide. The change means healthcare organizations urgently need to educate providers on the importance of improved patient care documentation. The Winthrop University Hospital clinical documentation improvement (CDI) specialists and HIM team have presently implemented a new query for acute myocardial infarctions to help. The newly created forms incorporate the language necessary to capture documentation within these two new areas of enhanced specificity. The team reviewed the queries' content, structure, design, and use to ensure they would be effective and accepted.
Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director for HCPro, a division of BLR, in Danvers, Massachusetts, and ACDIS Advisory Board member Mark LeBlanc, RN, MBA, CCDS, clinical documentation manager at Hennepin (Missouri) County Medical Center, donated this sample ICD-10-CM burn query.
Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director for HCPro, a division of BLR, in Danvers, Massachusetts, provided this query to use when a physician admits a patient with a history of alcoholism but provides no diagnosis.
William Haik, MD, FCCP, CDIP, director of DRG Review, Inc., and Cheryl Ericson, RN, MS, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS Trainer, clinical documentation improvement education director at HCPro, Inc., answered these questions about physician queries as part of the HCPro webcast, Physician Queries: Comply With the New ACDIS/AHIMA Guidance.
This policy establishes guidelines for inpatient physician queries. It is provided by Donald A. Butler, Manager of Clinical Documentation at Vidant Medical Center in Greenville NC. It was originally published on the Association for Clinical Documentation Improvement Specialists website.
Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI education director for HCPro in Danvers, Massachusetts, and ACDIS Advisory Board member Mark LeBlanc, RN, MBA, CCDS, Clinical Documentation Manager, at Hennepin (Missouri) County Medical Center, donated this sample ICD-10-CM fracture query.
Use this query when the physician admits a patient with a history of alcoholism but provides no diagnosis. Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI Education Director for HCPro Inc., in Danvers, Massachusetts, provided this query.
