Table of Contents
What is criteria for chronic respiratory failure?
Respiratory failure is a clinical condition that happens when the respiratory system fails to maintain its main function, which is gas exchange, in which PaO2 is lower than 60 mmHg and/or PaCO2 is higher than 50 mmHg. Respiratory failure is classified according to blood gases abnormalities into type 1 and type 2.
When do you need to query the documentation?
AHIMA guidelines state that a query should be considered when health record documentation includes the following: Conflicting, imprecise, incomplete, ambiguous, or inconsistent documentation. Associated clinical indicators related to a specific condition. A diagnosis without an underlying clinical validation.
When is it appropriate to query a physician?
According to AHIMA guidelines, coders should only query a physician when the documentation: Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent. Provides a diagnosis without an underlying clinical validation.
How do you write a compliant physician query?
What is a Query?
- Be clear and concise.
- Contain clinical indicators from the health record.
- Present only the facts identifying why the clarification is required.
- Be compliant with the practices outlined in this brief.
- Never include impact on reimbursement or quality measures.
Which of the following requires a query to the physician regarding clinical documentation?
A process to facilitate the accurate representation of a patient’s clinical status in the patient’s health record. Which of the following requires a query to the physician regarding clinical documentation? Documentation is conflicting, incomplete, illegible, ambiguous, or inconsistent.
What is considered a leading query?
A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure. The justification (i.e., inclusion of relevant clinical indicators) for the query is more important than the query format.
What is an example of leading query?
An example of a nonleading query might be: Can you further specify the etiology of the patient’s pneumonia? But here’s AHIMA’s example of a leading query: Is the patient’s pneumonia due to aspiration? Such queries can get a hospital in trouble.
What is a query template?
A query template creates a graphical interface that simplifies running a query with different parameters. This allows an end-user to easily change the values that a query uses without needing to access or understand the underlying SQL or SPARQL code.
What are the 2 types of respiratory failure?
Respiratory Compromise Types
- Type 1 Respiratory Failure (hypoxemic): is associated with damage to lung tissue which prevents adequate oxygenation of the blood.
- Type 2 Respiratory Failure (hypercapnic): occurs when alveolar ventilation is insufficient to excrete the carbon dioxide being produced.
What assessment findings indicate respiratory failure?
Assessment of respiratory sounds may include inspiratory or expiratory ‘wheeze’, which may indicate bronchospasm. Upper airway secretions may also be heard as gurgling sounds. Chest movement should be assessed for its symmetry and pattern.
How is respiratory failure diagnosed?
A doctor may diagnose you with respiratory failure based on the oxygen and carbon dioxide levels in your blood, a physical exam to see how fast and shallow your breathing is and how hard you are working to breathe, as well as the results of lung function tests.
What is a CDI query?
What are CDI queries? Clinical documentation specialists (CDS) send CDI queries to: Clarify diagnoses. Clarify ambiguous/conflicting documentation. Capture specificity required for accurate coding.
What is a clinical validation query?
▶ The process of reviewing physician documentation and. determining whether the correct codes and sequencing were. applied to the billing of the claim.
What is a physician query process?
“A physician query is defined as a written question to a physician to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in the patient’s health record.”
What is an example of a non leading query?
Non-Leading query example: A patient is admitted for a right hip fracture. The H & P notes that the patient has a history of chronic congestive heart failure. A recent echo shoed left ventricular EF of 25%.
What is a query transform?
Query Transform: Query Transform is similar to a SQL SELECT statement. It can perform the following operations- Choose (filter) the data to extract from sources. Join data from multiple sources. Map columns from input to output schemas.