CDI Scenarios

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…

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…

Topic: Coma H&P: 65-year-old female presenting with obtundation. Per report patient was in her usual state of health until the AM of date of admission when she suffered a sudden onset and progressive worsening headache. Family notes she progressed from lethargy to obtundation at which time EMS was called. Patient noted to have pressures in…

Topic: Outpatient CDI: Atrial Fibrillation Office Visit 2/15/2021: 78-year-old gentleman, lives with wife. Recently hospitalized from 1-2-2021 to 1-7-2021 for Acute MI and Atrial fib with RVR. No voiced complaints. No complaints of heart racing, chest pain. Able to walk around house, up and down flight of steps without stopping.  Seen last week by Ostomy Nurse…

When implementing outpatient CDI in a physician practice, there are 10 steps you must follow to be successful. Assess Current State Define and Align Set Program Goals Determine Return on Investment Staffing Infrastructure Define Workflow Communicate and Educate Performance Expectations Monitor and Track Ongoing Evaluation However, the following steps are considered keys to an effective…