CDI Tip: Pediatric Respiratory Failure
Diagnostic Criteria for Acute Respiratory Failure in Pediatric Patients Provider documentation often describes the patient’s symptoms and assessment without stating the words “acute respiratory failure.” If clinical indicators support the presence of acute respiratory failure, a query should be sent. Providers frequently use templated notes that are copied/pasted into subsequent notes. This is a great…
Holiday 2023 CDI Scenario Discussion
Topic: Managing Winter Blues & Holiday Stress The holiday season can be a time of great joy, and for many, great stress. The presence of gloomier weather, time change due to the end of daylight savings, and overall increase in demands and obligations further contribute to feelings of stress, depression, and seasonal affective disorder. Winter/Seasonal…
Monthly CDI Scenario Discussion – November 2023
Topic: Adverse Reactions to Drugs & Toxins/Poisoning/Underdosing/Toxic Effects Common definitions for this discussion: Provider documentation needs to be clear whether a drug was taken as directed or improperly administered to determine an adverse effect vs. poisoning. For example, a patient with a GI bleed due to Coumadin therapy would need clarification if the Coumadin was…
Monthly CDI Scenario Discussion – October 2023
Topic Outpatient CDI: Pacemaker Status, Sacroiliitis Office Visit: 76-year-old female, lives alone. Follow up re: Cardiology, Orthopedic (low back pain) follow up, refills needed. PMH: Hypothyroidism, CAD, Osteoarthritis, Lung Cancer, Pacemaker status, lawn mower accident as teenager- amputation of fourth, fifth toe on left foot. Home medications: Oscal, Synthroid, Losartan Vitals: BP 115/64, HR 98,…
UASI CDI Monthly Scenario Discussion – Clinical Validation of Acute Kidney Injury
Topic: Clinical Validation of Acute Kidney InjuryH&P: 79 y/o F presents with cloudy urine and labored breathing. Patient has suprapubic catheter draining to bedside bag which was last changed 10 days prior per daughter. Patient started on IV ceftriaxone, IV furosemide, and 1 liter NS bolus. Suprapubic catheter was changed during hospitalization.PMH: chronic systolic CHF,…
UASI Monthly CDI Scenario Discussion – Rhabdomyolysis
H&P: 38 y/o male presents with nausea, vomiting, dizziness, dark urine, and thigh pain after participating in a marathon. PMH: ADHD Home medications: Adderall XR 20mg once daily Vitals: HR 125, RR 23, BP 90/42 PE: lethargic, dry mucous membranes, poor skin turgor, thigh muscle pain Labs: Admission labs -calcium 7.0 mg/dl , Potassium 4.4,…
UASI Monthly CDI Scenario Discussion – Functional Quadriplegia
H&P: 97yo female presented to the ER from her nursing home after developing a fever. Patient complains of a productive cough for 2 days. Patient is bedbound at the nursing home and dependent on the staff for all ADLs. Impression: Suspect pneumonia, will obtain sputum culture and start antibiotics. PMH: Dementia, severe arthritis with contractures,…
UASI Monthly CDI Scenario Discussion: Catheter Associated Urinary Tract Infection (CAUTI)
H&P: 78 yr. old female admitted with abdominal pain. Caregiver states the patient is complaining of abdominal pain, and only 75mL of cloudy urine emptied from her suprapubic catheter overnight. PMH: recurrent UTI, cerebral palsy with chronic contractures, urethral stricture with chronic suprapubic catheter, seizure d/o. Home medications: Lisinopril po, Loratadine po, Methocarbamol po, Phenobarbital…
Antimicrobial Resistance CDI Scenario
We’d like to extend our sincerest gratitude to Katherine from Lifepoint Health for catching an error with this CDI scenario. The error has been corrected. H&P: 85 yo F presents to the ED from home with abdominal pain and fatigue. UA was positive for UTI. Will obtain Urine Culture, replace foley, and start Levaquin while…
Syndrome of Inappropriate Antidiuretic Hormone (SIADH) CDI Scenario
April 2023 H&P: 67-year-old male sent to ER from Rehab with altered mental status and lethargy. Has been complaining of headache for last 24 hours. Patient is currently oriented to self and is unable to participate in exam. CT Scan completed at Rehab with no change to ICH, no midline shift or brain compression. Pt…
How do the CMS-HCC model changes impact you?
The eagerly anticipated changes to the CMS-HCC model are here. There are some positive and negative impacts that are coming your way. How you fare is dependent on your population though the model is predicting a 3.32% increase in payments to Medicare Advantage plans over three years. As a result, shoring up your risk adjustment…
Comparing Codes Across ICD Versions: Syncope
Mary Stanfill compares code assignments and categories for the common condition of syncope in ICD-10-CM and WHO ICD-11