Soi severity of illness - Study guides, Class notes & Summaries

AHIMA - ANSWER-American Health Information Management Association ACDIS - ANSWER-Association of Clinical Documentation Improvement Specialists IDT - ANSWER-Interdisciplinary Team LOS - ANSWER-Length of Stay The RHIT, RHIA or CCS should have how many years of inpatient coding experience before becoming a CDI specialist? - ANSWER-at least 3-5 years Hospitalists - ANSWER-Physicians whose primary professional focus is the general medical care of hospitalized patients Timeframes for...

CCDS questions with complete solutions 2023A. Bleeding gastric ulcer A patient is admitted from the emergency department (ED) with a diagnosis of weakness and anemia. After admission and further treatment with packed red blood cells (PRBC), GI consult, and endoscopy, the physician includes the following diagnoses in the discharge summary: anemia, suspected bleeding gastric ulcer, and GERD. What would be the most appropriate principle diagnosis? A. Bleeding gastric ulcer B. Anemia C. GERD ...

Cert - ANSWER-Comprehensive error testing rate Cpt - ANSWER-Current procedural terminology. The amas list of 5 digit codes used to report outpatient hospital and Physicians Medical and surgical services. CPT is used to report outpatient or Physician Office claims only and is updated annually in January. Hac - ANSWER-Hospital-acquired conditions are defined as for discharges occurring on or after October one 2008 ipps hospitals will not receive additional payment for cases when one of the s...

ROM Risk of mortality SOI Severity of illness Brainpower Read More MCC Major complication or comorbidity CC Complication or comorbidity MS-DRG Medicare Severity-Diagnosis Related Group LOS Length of stay CDI Clinical Documentation Improvement Clinical Documentation Improvement a program that promotes specificity and excellence in documentation Who participates in CDI program? Physicians and mid-levels, CDI specialists, coders, ...

Cert - ANSWER-Comprehensive error testing rate Cpt - ANSWER-Current procedural terminology. The amas list of 5 digit codes used to report outpatient hospital and Physicians Medical and surgical services. CPT is used to report outpatient or Physician Office claims only and is updated annually in January. Hac - ANSWER-Hospital-acquired conditions are defined as for discharges occurring on or after October one 2008 ipps hospitals will not receive additional payment for cases when one of the s...

Who sets the official Guidelines for coding and reporting (ICD-10)? American Hospital Associates (AHA) American Health information management association (AHIMA) National Center for Health Statistics (NCHS) Center for Medicare and Medicaid Services (CMS) AHA Serves as a clearing house for issues related to use of ICD-10 codes services in representation and advocacy role on national classification and data issues publisher of the AHA coding Clinic (updated quarterly AHIMA ...

ROM - ANSWER-Risk of mortality SOI - ANSWER-Severity of illness MCC - ANSWER-Major complication or comorbidity CC - ANSWER-Complication or comorbidity MS-DRG - ANSWER-Medicare Severity-Diagnosis Related Group LOS - ANSWER-Length of stay CDI - ANSWER-Clinical Documentation Improvement Clinical Documentation Improvement - ANSWER-a program that promotes specificity and excellence in documentation Who participates in CDI program? - ANSWER-Physicians and mid-levels, CDI specia...

CDIP Questions and Answers Rated A+ CDI program data includes: 1. All cases that were reviewed 2. Number of cases with queries 3. Nature of the query 4. Physician response to the query Queries should only be asked: 1. If there is clinical evidence that the documentation is imcomplete or does not meet one of the seven criteria for high-quality clinical documentation. 2. By an individual with solid clinical knowledge. 3. In an open-ended manner (no yes or no questions) 4. In a nonleading manner. ...

POA - ANSWER-Present on admission Concurrent reviews - ANSWER-CDI specialist reviews the patient record while the patient is in the hospital Ethical - ANSWER-Conforming to accepted standards of conduct Ethical Queries - ANSWER-Queries that do not lead the physician to a particular answer If you have two conflicting diagnoses by two providers, who should make the final decision? - ANSWER-Attending physician Legible - ANSWER-the record is clear enough for the reader to comprehend an...

POA Present on admission Concurrent reviews CDI specialist reviews the patient record while the patient is in the hospital Brainpower Read More Ethical Conforming to accepted standards of conduct Ethical Queries Queries that do not lead the physician to a particular answer If you have two conflicting diagnoses by two providers, who should make the final decision? Attending physician Legible the record is clear enough for the reader to comprehend and e...