Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, provided this documentation and coding example for reporting fetal status for ICD-9-CM and ICD-10-CM.
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.
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.
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 at HCPro, a division of BLR, in Danvers, Massachusetts, provided this sample multiple-choice query for chest pain.
Rebecca A. “Ali” Williams, RN, BSN, CCDS, manager of documentation integrity at Spartanburg Regional Medical Center and Village at Pelham Hospital in Spartanburg, S.C., shared this sample query for a subarachnoid bleed in ICD-10-CM.
These sample malnutrition queries were donated by Cheryl Ericson, MS, RN, CCDS, CDIP, 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 (Mo.) County Medical Center, who spoke during the June 10 webinar “Physician Queries: Ensure Effective, Compliant, Regulatory-Based Clarifications.” The queries also appear on the ACDIS website.
