Clinical Documentation Improvement (CDI) Assignment
Part 3 – Your facility received an initial DRG validation denial letter from the RAC. The case scenario includes a 75-year-old patient admitted through the Emergency Department for renal failure and COPD exacerbation. The reason for admission is COPD exacerbation. The physician also documented protein-calorie deficiency malnutrition in the discharge summary. The Clinical Documentation Specialist notices that the physician’s supporting documentation is missing, including whether this condition was present of admission. Clinical Documentation Improvement (CDI) Assignment
Task 1: Realizing that you will need to add Querying to your process list, clearly identify the intent of queries included in a procedure format and provide examples of why a provider might receive a query.
Task 2: It is time to address the case at hand.
The RAC suggests that the patient did not have protein-calorie deficiency malnutrition.
Identify a scholarly article on protein-calorie deficiency malnutrition (i.e. Google Scholar or other scholarly resources http://scholar.google.com/); then write a query to the physician to address the MS DRG for principle diagnosis of COPD exacerbation with protein- calorie deficiency malnutrition.
You may add additional detail to the case such as medications, treatments, and such to support query development. *Remember, you do not want to make your query leading! Clinical Documentation Improvement (CDI) Assignment