Unsolved Mysteries
I'm a grouping, a logic, a system so grand, I decide the payment for the patient in hand. With MDC, DRG, and a host of codes, I lead to the money, a heavy load.
What am I?
The DRG (Diagnosis Related Group)
I'm a letter, but not from an alphabet, I tell a coder what they're seeing yet. I can be "A" for principal, or "B" for a secondary diagnosis, I'm a key part of documentation, and my presence is a bonus.
What am I?
The POA (Present on Admission) indicator
I'm a code, but not for a bank, I'm used when a patient's in a state of blank. I describe a procedure that's not yet done, Or a diagnosis that's not a final one.
What am I?
The Z-code
One diagnosis can change it all, From base DRG to major haul. From base DRG to major haul. Is it acute? Is it new? Is it acute? Is it new? That’s what I must help define for you. That’s what I must help define for you. What am I solving?
The presence of an MCC
I'm a document, not a book of fiction, I describe a patient's whole affliction. I include the history, the exam, the plan, The final summary written by a physician's hand.
What am I?
The Discharge Summary
I'm a list on a screen, or maybe in a book, But for my presence, you must take a second look. I'm a collection of diagnoses, but here's the key, I'm only for issues that are active, you see. What am I?
The Active Problem List
I'm a document, a snapshot in time, I tell a story, a medical rhyme. I'm written on admission, a detailed view, Of the patient's condition, both old and new.
What am I?
The History and Physical (H&P)
Confused, drowsy, not quite awake, The reason? That’s what’s at stake. The reason? That’s what’s at stake. Is it delirium? Or metabolic fog? Is it delirium? Or metabolic fog? I need more clues to clear the log. I need more clues to clear the log. What’s the possible diagnosis?
Encephalopathy (maybe metabolic or toxic)
I'm a word, but not in a book, I'm a diagnosis that needs a second look. I'm used when a condition is treated, And I'm a sign that the patient has completed their treatment.
What am I?
The term "resolved"
I'm a document, a form, a part of the chart, I show the daily progression of a patient's heart. I have a list of medications, vital signs too, I'm a record of care, for me and for you.
What am I?
The Progress Notes
I’m not a symptom, I’m not a guess,
I need a provider’s clear express.
Without me, the query’s just a draft,
With me, it’s CDI’s golden craft.
What am I waiting for?
A provider response
When something’s missing, I don’t assume, I craft a message, polite and in tune. I craft a message, polite and in tune. I’m not correcting, just clarifying right, I’m not correcting, just clarifying right, So coders and payers can see the light. So coders and payers can see the light. What do I send?
A CDI query
I’m the bridge from vague to clear,
I help the truth appear right here.
Was it ruled out or truly found?
I guide the team with logic sound.
What am I?
Clinical validation
I don’t prescribe, I don’t diagnose,
But I help define what matters most.
When I rise, the stakes do too—
I show how sick, not just what’s new.
What am I?
Severity of illness
I’m not a suggestion, not a guess,
I follow rules to avoid a mess.
I must be clear, concise, and fair,
And never lead the doc to err.
What am I?
A compliant query
I don’t carry a stethoscope, but I investigate each line, I dig through notes to make sure they align. I dig through notes to make sure they align. MCCs and CCs are clues I chase, MCCs and CCs are clues I chase, To tell the patient’s story with accuracy and grace. To tell the patient’s story with accuracy and grace. What am I?
A CDI specialist
I don’t assume, I don’t imply,
I ask with care, not with a sly.
I offer choices, not just one,
So documentation’s rightly done.
What am I?
Multiple-choice query format
I’m not a tool, I’m not a hand,
But I help the record understand.
Was it open, closed, or scoped?
I need the method fully scoped.
What am I?
Approach in procedure coding
I’m not a diagnosis, not a plan,
But I define what’s done by hand.
Was it cut, removed, or fixed anew?
I help the coder know what’s true.
What am I?
Root operation
“Kidney injury” — hmm, not quite right, Is it chronic? Acute? Stage 1 or Stage 5 plight? Is it chronic? Acute? Stage 1 or Stage 5 plight? I search for labs, the BUN and creatinine, I search for labs, the BUN and creatinine, To help the doc write what they mean. To help the doc write what they mean. What mystery am I solving?
The specificity of renal failure