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Q&A: Receiving query responses from providers

Have CDI questions?

Have CDI questions?

Q: Our hospital is having a hard time getting our physicians to respond to queries, do you have any suggestions on how to get them to reply?

A: The most important thing is make sure the query is concise and contains clinical indicators from the record. You also want to use different methods of contacting the physician as well. Various points of contact include within the electronic health record, via e-mail, by phone, or by having your CDI team visit them on the floor. [more]

Q&A: Documenting excisions in dermatologic settings

ask ACDIS

Have CDI questions?

Q: I work in dermatology and need to know what documentation is required for excisions. We are struggling with getting paid.

A: In dermatology, you often find vague documentation like “lesion” and “mass.” So the physician needs to be much more graphic as far as whether the lesion is red, itchy, scratchy, burning, and/or abnormally sized. If you can get the actual size of a lesion or a mass that they are going to excise, they also need to document the size of the excision.

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