Topic: HIV Scenario: 65 year old hemophiliac presents with poor appetite, difficulty swallowing, and weight loss History and Physical: HPI: Recently moved to the US; reports poor appetite and sore throat over the last 3 months; reports being unable to get out of bed for a week; at patient’s last office visit, his lab work… Read More »Monthly CDI Scenario Discussion – May 2020
Topic: Multiple Significant Trauma Scenario: 65 year old male with a PMH of CAD, HTN, and Hyperlipidemia on Metoprolol and Lipitor who presented following a 10 foot fall onto the ground from a ladder while cleaning out the gutters. Per H&P pt. fell on his back striking his head with wife reporting to EMS he was… Read More »Monthly CDI Scenario Discussion – April 2020
Topic: Pancytopenia Scenario: A 51 year old female presents with nausea, vomiting, and weakness History & Physical: HPI: 51 year old female recently diagnosed with leukemia presents with nausea, vomiting, poor appetite, and weakness. Last chemotherapy treatment was one week prior to presentation. PMH: Osteoarthritis, diabetes mellitus type 2, HTN, obesity (BMI 35), no history… Read More »Monthly CDI Scenario Discussion – March 2020
Topic: Functional Quadriplegia Scenario: 72 year old male admitted from a skilled nursing facility with complaints of uncontrolled blood pressure by SNF staff. PMH of severe Alzheimer’s dementia, CAD, HTN, CKD3 with baseline creatinine of 1.5 Per H&P: SNF staff reported difficulty controlling blood pressure over the last 24 hours. BP at SNF reported to… Read More »Monthly CDI Scenario Discussion – February 2020
Topic: Pathological Fracture Scenario: 82 year old female presented with right hip pain after ground level fall History & Physical: HPI: 82 year old female presented with right hip pain after ground level fall. Patient stated that she tripped over the cat and landed on her right hip. She felt an immediate severe pain and… Read More »Monthly CDI Scenario Discussion – January 2020
Topic: GI bleeding Scenario: 80 y/o female presents with coffee ground hematemesis with a PMH of GERD, CAD, and Iron deficiency Anemia. She has home medications of Protonix PO daily, SlowFe PO daily, and ASA 81mg PO daily. H&P notes: “acute upper GI bleed” with non-compliance with the Protonix and SlowFe because she says “they… Read More »Monthly CDI Scenario Discussion – December 2019
This training includes: Discussion of 2020 MS-DRG changes with CDI tip recommendations Discussion of 2020 IPPS changes with CDI tip recommendations Discussion of 2020 ICD-10-CM updates with CDI tip recommendations Why It’s Important: Coding is the basis of clinical documentation improvement Understanding coding fundamentals will assist in knowing what to look for in regards to… Read More »Code Updates and Tips for CDI
Topic: Fever of unknown origin Scenario: 65 year old male presented to the ED with a five-day history of increased congestion, cough, subjective fever, worsening lethargy, some confusion, weakness, and decreased oral intake. In the ED, the patient was febrile 102.0 F, heart rate 90, BP 112/71, RR18, SPO2 94% on room air. CT of… Read More »Monthly CDI Scenario Discussion – November 2019
Topic: Clinical Validation: Acute Post Operative Pulmonary Insufficiency/Acute Postoperative Respiratory Failure Scenario: H/P: 65 y/o male with past medical history of DMII, HLD, HTN, and obesity admitted with chest pain worse on exertion. Medications: Insulin, Metoprolol, Lisinopril, ASA, Crestor. BMI 34. Patient had a positive stress test. Cardiac cath shows severe three vessel disease and… Read More »UASI Monthly CDI Scenario Discussion – October 2019
Topic: Altered Mental Status, Dementia with Encephalopathy Scenario: 85 y/o female admitted with Sepsis secondary to UTI and altered mental status. History of dementia. Decreased responsiveness noted by patient’s sister who reports this is significantly different than her usual state. H/P: “Patient is disoriented, confused with decreased responsiveness, hard to arouse. The degree at onset… Read More »Monthly CDI Scenario Discussion – September 2019