Study Guide Review 2024 Updates

What popular strategy is used to implement an EHR that creates additional compliance risks for an organization {Ans: "point and click"}What can be a red-flag when looking at hospitals DRGs? {Ans: A vague or symptomatic principal diagnosis}Where does the coder normally begin the review? {Ans: The face sheet or admission discharge transfer information (ADT)}What is the key to success and sustainability of the CDI program? {Ans: Physician Support}When should a medical history and physical examination be completed? {Ans: - No more than 30 days before or 24 hours after admission or registration - Prior to surgery or procedure requiring anesthesia services}If CDI specialists can identify trends of certain diagnoses or procedures over time, they can use this information to design follow-up education targeted at specific physicians, services, or the entire medical staff if the documentation problem appears to be a global one. T/F? {Ans: True}