Paul Evans, RHIA, CCS, CCS-P, CCDS, manager of regional clinical documentation and coding integrity, at SutterHealth in San Francisco, California, offered this sample query to ACDIS for anemia specificity.
The attached PDF is a sample query form regarding multi-system organ failure donated to ACDIS by Katy Good, RN, BSN, CCDS, CCS, clinical documentation program coordinator, AHIMA approved ICD-10-CM/PCS trainer, at the Flagstaff Medical Center in Flagstaff, Arizona.
The following sample query was donated to ACDIS by Advisory Board member Paul Evans, RHIA, CCS, CCS-P, CCDS, manager, Regional Clinical Documentation at Sutter West Bay in San Francisco. Contact him at evanspx@sutterhealth.org.
Documentation and coding of severe sepsis matters in terms of patient risk assessment and establishing sepsis as a diagnosis, as well as the effect of such documentation (and subsequent code assignment) on quality measures.
