Best Practices

World-class advice to address real-world challenges.

CDI Tips: Properly Capturing Lactic Acidosis

CDI Tips: Properly Capturing Lactic Acidosis

A recent discussion regarding lactic acidosis in a patient with sepsis has prompted a review of some important points that need clarification.   First and foremost, lactic acidosis is not considered inherent to Sepsis. Additionally, acidosis is not noted as an...

CDI Tips: Dementia

CDI Tips: Dementia

Dementia: Will we need more queries? The short answer is yes! We need documentation of none, other, or a specified type of mood disorder.  But here is the long answer: “Dementia The ICD-10-CM classifies dementia (categories F01, F02, and F03) on the basis of the...

Coding Tip: Lupus

Coding Tip: Lupus

When Lupus (unspecified) is documented in a record, there is no default code. Therefore, it is important to have providers document this condition as precisely as possible. For instance, document SLE (systemic lupus erythematosus) instead and add any complications...

Coding Tip: Cachexia (R64)

Coding Tip: Cachexia (R64)

Cachexia (R64) is also known as ‘wasting’ or ‘wasting syndrome’. It is a general state of weakness involving marked weight and muscle loss. Emaciated is another term that may be found in the documentation that also maps to code R64. These diagnoses are often missed...

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