CDI Queries
If this status cannot be clearly identified, the condition will not meet the criteria for PDX and may prompt a query.
What is POA status
Y=Condition was present at the time of inpatient admission
N=Condition was not present at the time of inpatient admission
U=Documentation is insufficient to determine whether condition was POA
W=Provider is unable to clinically determine whether condition was POA
The degree a CDI could have.
What is an RN, RHIA, RHIT, MD or DO?
Unlike MS-DRGs, this payment methology is severity adjusted and is used by more than half of state Medicaid programs and is also recognized by some private payors to provide a more accurate capture of a patient's complexity
What is APR-DRG
Can be further described as pathological, stress, or non-traumatic
What are fractures.
Fun fact from 3M-
Careful review of CT scans and X-rays is essential as pelvic fractures are frequently overlooked. The presence of both a femoral fracture and pelvic fracture result in qualification for and assignment to Multiple Significant Trauma (MST), MDC 24.
Number of children Donna has.
What is 2 boys, Tyler and Ryan.
This is a documented summary capturing the focus of a non-leading conversation or discussion with a provider regarding reportable conditions or procedures and includes the reason for the discussion, clinical indicators and options with which to respond.
What is a verbal query.
A set of guidelines for professional behavior of CDIs
What is the ACDIS Code of Ethics
This publication is dependent on the unanimous agreement of The Centers for Medicare & Medicaid Services, Centers for Disease Control National Center for Health Statistics, American Hospital Association & American Health Information Management Association
What is the AHA Coding Clinic, providing ICD-10-CM and ICD-10-PCS coding advice and official guideline coding advice in a quarterly publications
Measurement of overall blood glucose concentrations over the past 2-3 months.
What is HbA1c.
The American Association of Clinical Endocrinologists recommends a target of 6.5% or less. The American Diabetes Association indicates that diabetes is diagnosed at an A1C of greater than or equal to 6.5%.
Good diabetic control: 2.5% - 5.9%
Fair diabetic control: 6% - 8%
Poor diabetic control > 8%
Institution where Emily earned her BSN
What is University of Lynchburg in Lynchburg VA
A reason to celebrate every year during the third week of September
This year, September 15-19
What is CDI Week !!!
Why is a week of national recognition needed? CDI specialists need a week of recognition to:
• Recognize the unique skills and expertise of CDI specialists • Increase public awareness of the CDI profession • Positively affect the personal and organizational performance of CDI specialists • Provide broader education on the importance of quality documentation and its connection to patient care
(watch for email with more info)
Defined as the sum of all Medicare DRG relative weights divided by the total number of discharged Medicare cases.
What is the CMI (case-mix index)
The Deficit Reduction Act of 2005 required a quality adjustment in MS-DRG payments for certain conditions know as this.
What is HACs (hospital acquired conditions)
CMS stopped paying for conditions caused, even inadvertently, by the care the facility provided.
This is an overdistended gallbladder filled with mucoid or clear fluid. Also called mucocele, it is easily identified via an ultrasound. Causes include gallbladder obstruction due to stones, tumors, or strictures, extrinsic compression due to malignancies, or prolonged use of TPN. It is not considered inherent to any gallbladder condition; therefore, it may be captured as a secondary diagnosis when documented.
What is Hydrops of the gallbladder.
Hydrops is a CC.
Who is Deb's favorite entertainer (hint, first born son may or may not share first name)
Who is Jackson Browne
The reason CDI sends queries to providers.
What is to obtain THE CLINICAL TRUTH
or
What is a question to clarify the providers documentation?
This team member with whom we collaborate is not allowed to infer, extrapolate, deduce or interpret in any way what a provider intended to say.
What is a coder.
These agencies, respectively, administer certification exams to provide special recognition to those clinical documentation specialists who demonstrate mastery of an acquired body of knowledge and skills in clinical documentation integrity through successful completion of the certification process.
ACIDS, CCDS
AHIMA, CDIP
A reaction to a drug, medicament, or biological that was correctly prescribed and properly administered.
What is an Adverse effect.
The principal diagnosis for an adverse effect is the manifestation or nature of the adverse effect. The resultant MS-DRG will depend on the manifestation. Common adverse effects include tachycardia, delirium, gastrointestinal hemorrhage, nausea/vomiting, hypokalemia, hepatitis, acute renal failure, and acute respiratory failure.4
If there is no mention of a drug having been taken incorrectly, it is to be assumed that the drug reaction is an adverse effect, and the drug was taken correctly.
Mechel's current favorite dessert.
What is tiramisu.
The process of accounting for known health conditions, allowing for comparison of wellness among patients. Demographic information and diagnosis codes are utilized to determine potential risk, thus providing a method to predict costs and quality of care measures.
What is Risk Adjustment
This team member often takes on mentoring or coaching for colleagues in their immediate circle of influence and may be considered a cheerleader for CDI efforts.
What is a physician champion, an asset to a strong CDI program.
Two parter:
The AHA, AHIMA, CMS, NCHS together are known as this, and together release updated rules every October 1 known as this.
"Cooperating Parties"
Official Guidelines for Coding and Reporting.
This may present as acute sudden severe joint/bone pain is the most common symptom but contributing factors may include dehydration, infection, hypoxia, exposure to cold or alcohol/drug abuse. Other symptoms include severe acute abdominal pain, chest pain with coughing up of blood in some cases.
What is sickle cell crisis.
Review for clinical indicators of infection, as that is often a trigger.
Review for s/s of Acute Chest Syndrome, a form of acute lung injury dx'd by findings on CXR, fever, and/or respiratory symptoms.
In 2009 AtlantiCare is one of only five organizations in the country to earn this accolade. It is the nation’s highest presidential honor for performance excellence.
What is the Baldrige Award.