This form can be used to query physicians for additional information for HIV patients. It was submitted by Ameena AbdulMalik of Hermann Memorial Healthcare System in Texas. It was originally published by the Association of Clinical Documentation Improvement Specialists in July.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, offers case studies to show how providers must document a diagnosis of heatstroke, in addition to symptoms, for coders to report ICD-9-CM or ICD-10-CM codes for heatstroke.
This document is a formal approach to documenting postoperative respiratory failure. It is provided by Paul Evans, RHIA, CCS, CCS-P, CCDS, of Sutter Health in San Francisco.
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.
The attached PDF reviews documentation and coding needs for complications and establishes policies and procedures for coders and CDI professionals to follow. Created by Paul Evans, RHIA, CCS, CCS-P, CCDS, the document provides complication definitions, explains when queries are necessary, and explores specific documentation concerns about conditions such as Incidental Serosal Tear and postoperative atrial fibrillation.
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.
