CDI Insights
The CDI Scenario for January 2022 covers complication of a device, specifically with a Foley catheter causing UTIs.
December’s CDI Scenario covers hemiplegia secondary to stroke. A 78 year old diabetic male with a history of falling goes to the doctor.
November’s CDI Scenario covers neurogenic shock and spinal shock. A 58 year old male enters the ER after hitting his head.
October’s CDI scenario covers pneumonia and COVID-19. A 60 year old male patient presents with COVID and worsening hypoxia.
H&P: 58 yr old male with chest pain and SOB presents to the ER. Troponins ordered along with EKG revealing nonspecific ST changes with rising levels. Cardiology consult for NSTEMI with orders for ASA 325mg x1, Nitropaste, and o2. While waiting on consult, patient became lethargic and pale with fingertip cyanosis noted. Repeated VS showed:…
Given the heightened focus on documentation and impacts to healthcare organizations from both a financial and quality perspective, it is imperative that clinical documentation improvement (CDI) leaders implement an effective strategy to develop a physician advisor program. The success of a CDI physician advisor program hinges upon defining the physician advisor’s role. A physician advisor…
H&P: Patient presented with shortness of breath and palpitations noted to be in atrial fibrillation and with AKI. Patient with baseline creatinine of 1.1, noted as 1.5 on admission. Give IVF for AKI and monitor labs. Platelets 64, consult Hematology for ITP treatment recommendations PMH: Idiopathic thrombocytopenia purpura (ITP) treated in past with IVIG with…
Click the button below to download a PDF of Alyson Swinehart’s Lunch and Learn, “Developing Introduction to CDI for Providers and Physician Advisors.”
Hierarchical Condition Categories (HCCs) have been around since 2004. However, with their increased impact on professional fee reimbursement due to the implementation of MACRA, HCCs have become a hot topic and, therefore, a focus point in every coding arena. Now, physicians will be compensated based on the estimated health cost according to risk profiles, as…
Topic: Outpatient Major Depressive Disorder (MDD) Office visit 6/1/21: 65 y/o Caucasian, female seen in office for severe malaise and fatigue for last 6 months. PMH: Chronic Kidney Disease, Hypertension, Diabetes Mellitus type 2 Home Medications: Metoprolol 50mg QD, Glucophage 500mg QD, ASA 81mg QD, Multivitamin, Calcium Vitals: T: 97.5, HR:78, RR:20, BP: 130/78. HT:5’3”, WT…