Audrey G. Howard, RHIA, and Cheryl Manchenton, RN, BSN, of 3M Health Information Systems provided this example of a query for a documentation of a case involving a urinary tract infection due to insertion of a Foley catheter.
Auditing and monitoring, Health information management
The Office for Civil Rights recently published its audit protocol for its current privacy and security audits. These protocols give healthcare organizations an inside look at the inspection process. Our sister publication, Briefings on HIPAA, recently published this breakdown of the audit protocols key activities.
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.
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.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, provided these examples for anemia documentation for OB/GYN patients and the questions coders to ask in order to report the correct diagnosis.
Deborah K. Hale, CCS, CCDS, president of Administrative Consultant Service, LLC, in Shawnee, Okla, provided this pocket card to use when determining whether a patient should be admitted.
