The purpose of a clinical documentation improvement (CDI) program is to help health care facilities comply with government programs and other initiatives with the goal of improving health care quality. Thus, a CDI specialist initiates concurrent and retrospective reviews of inpatient records to identify __________ provider documentation.
a. abusive and fraudulent
b. conflicting, incomplete, or nonspecific
c. illegible physician queries and
d. redacted health insurance claims and
Question 2
A physician lists viral pneumonia as the final diagnosis. However, the coder notes that laboratory results state gram-negative bacteria.. There is also documentation of chest pain, fever, and dyspnea due to pneumonia. What should the coder do?
a. Assign a code to the final diagnosis of viral pneumonia
b. Code bacterial pneumonia, chest pain, fever, and dyspnea
c. Query the physician regarding the diagnosis of pneumonia
d. Report symptom codes for chest pain, fever, and dyspnea
Model for evidence-based clinical decision making.
Example of variance documentation
Sample Stress Management Program
Comparison of Paper Medical Records and Electronic Health Records
Disease: Major environmental health problems
Principles and Foundations of Health Promotion and Education (6th Edition)