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Coder vs. CDI is the industry's first talk show format podcast focused on bringing you interesting and new perspectives on clinical and coding topics. Regularly you'll hear the voices of Allen Frady, Amy Czahor, and Kyle Boyd discussing things that we all think but nobody wants to say out loud. Make sure you listen to our Saturday episodes when Dr. Stark, Physician Advisor Extraordinaire, will answer YOUR questions on clinical and coding topics -  You can submit your questions here.

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Show Notes: 
1 d. All multiple choice query answer options should only include clinically
relevant options (meaning those options that are supported by the
clinical indicators within the health record) and exclude clinically
irrelevant options (e.g., sodium level is 122 and a query is sent to
determine if a diagnosis can be provided; hypernatremia would not be
an appropriate answer option) And....(pg 5)  II. Diagnosis answer options that are not already documented in the health record must be supported by clinical indicators sourced from the medical record. These clinical indicators must be included within the query and (pg 6) V. Queries must be accompanied by clinical indicator(s)/evidence that:
a. Are specific to the patient and episode of care
b. Support a more complete or accurate diagnosis or procedure and (pg 7) III. Template elements should allow for inclusion of relevant clinical indicator(s) and evidence to support the query. Clinical indicators should include a citation of the location found within the health record. and (pg 7) IV. Template answer option(s) should include:
a. Only offer multiple choice answer options that are clinically credible
i. Remove answer options that are not clinically credible or relevant and (pg 14) All queries must meetthe same compliant standards regardless of how or when they are generated,
including those autogenerated by artificial intelligence (AI) and computer-assisted
coding (CAC), whether in real-time computer-assisted physician documentation
(CAPD) or after the episode of care is complete.

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