Revenue Cycle

Coding Q&A

Briefings on Coding Compliance Strategies, March 1, 2016

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Q: I was reviewing a case with one of our clinical documentation improvement (CDI) specialists this morning. The clinical indicators documented in the chart are elevated cardiac enzymes, shock, and demand ischemia. Cardiology documented "elevated cardiac enzymes in setting of shock representing a Type 2 injury." Also documented in another note is "demand ischemia." Should the CDI specialist query for more information?

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