CVA query

dvitalone1dvitalone1
in CDI Talk Archive
We have a new HIM director and she wants all the query forms revised. Our coding supervisor wanted me to ask the group if any of you have a CVA query you are willing to share. My email is dvitalone@comhs.org. Thanks, Dawn

Comments

  • mahmed1mahmed1
    edited May 2016
    attaching two query form one for current CVA and other is late effect of CVA.


    thanks,

    MA

    Sincerely,

    Mohammad Ahmed, M.D, CCS, CCDS,
    Certified Clinical Documentation Specialist
    Bronx Lebanon Hospital Center
    Health Information Management
    1650 Grand Concourse
    Bronx, NY 10457
    Phone: 718-518-5119
    Fax: 718-518-5634
    Email: mahmed1@bronxleb.org
  • dvitalone1dvitalone1
    edited May 2016
    Thank you so much Mohammad!

    Dawn M. Vitalone, RN
  • avery.trickeyavery.trickey
    edited May 2016
    These queries may want to be reviewed for compliance. They are leading in nature by telling the physician what to document.

    Thanks,
    Avery

    Avery E. Trickey, RHIA
    Lead Clinical Documentation Specialist
    Health Information Management
    Advocate BroMenn Medical Center
    309-268-5394
    avery.trickey@advocatehealth.com
  • paxnerospaxneros
    edited May 2016
    Dawn,

    Is it for a CVA or TIA? We have a query for TIA and one of our choices is "CVA/Stroke".

    We get admissions for CVA vs. TIA ( or vice versa) or TIA only. The wording I use:

    "Documentation in the medical record indicates this patient has been identified to have and/or is being evaluated and treated for TIA. "

    "Based on your medical judgment please document within the medical record the most likely, possible, probable, suspected underlying cause of this symptom and treatment:"

    (Choices)

    Stroke/CVA

    Transient Cerebral Thrombosis

    Transient Cerebral Embolism

    Partial Occlusion or. Stenosis of Pre-Cerebral Artery

    Partial Occlusion or Stenosis of Cerebral Artery

    Other

    Unknown

    Undetermined

    I also have a "notes" area where I will mention what meds have been ordered such as Plavix or Aggrenox which are both Anti-Thrombolytics.

    What we are trying to do is either have them document Stroke or give us the underlying cause of the TIA. TIA falls into a DRG which cannot be affected by MCC or CC and the above choices are affected.

    NBrunson, RHIA, CCDS
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