Clinical Documentation Integrity (CDI) Strategies for the Gastrointestinal System

Topics Covered: clinical documentation integrity for gastrointestinal diagnoses, CDI gastrointestinal system strategies, gastrointestinal CDI, UHDDS guidelines, CDI record review process, gastrointestinal disease documentation, diagnosis specificity requirements, compliant provider queries, clinical indicators, complications, comorbid conditions, underlying etiologies, severity of illness capture, SOI capture, risk of mortality capture, ROM capture, DRG assignment, quality outcomes, patient acuity documentation, GI signs and symptoms, abdominal pain, nausea and vomiting, dysphagia, diarrhea, abdominal distention, ileus, definitive diagnosis query, GERD documentation, pancreatitis documentation, diverticulitis documentation, cholelithiasis documentation, renal colic documentation, peptic ulcer disease documentation, GI cancer documentation, GI bleed documentation, ulcer documentation, irritable bowel syndrome documentation, gastroenteritis documentation, esophagitis documentation, bowel obstruction documentation, appendicitis documentation, small bowel obstruction documentation, gastroparesis documentation, dysentery documentation, celiac disease documentation, GLP-1 receptor antagonist adverse effect, upper GI hemorrhage, lower GI hemorrhage, rectal bleeding, hematemesis, melena, occult bleeding, hematochezia, esophageal varices, esophageal cancer, esophageal ulcer, Mallory-Weiss tear, gastric ulcer, gastric cancer, gastritis, Dieulafoy lesion, duodenal ulcer, pancreatic duct bleed, superior mesenteric artery syndrome, colitis, ischemic colitis, ulcerative colitis, infectious colitis, diverticulosis, colonic polyps, hemorrhoids, coagulopathy, colon cancer, rectal cancer, diverticular disease, Meckel’s diverticulum, gastrointestinal hemorrhage documentation, upper versus lower GI bleed, gastritis with bleeding, acute gastritis documentation, chronic gastritis documentation, underlying GI bleed etiology, GI bleed principal diagnosis, proton pump inhibitor treatment, EGD documentation, colonoscopy documentation, no active bleeding query, GI bleed due to malignancy, GI bleed due to alcoholic cirrhosis, GI bleed due to bacterial colitis, GI bleed due to gastritis with hemorrhage, GI bleed due to gastric ulcer with hemorrhage, esophageal varices with GI hemorrhage, cirrhosis documentation, liver failure documentation, portal blood flow documentation, alcoholism-associated cirrhosis, varices with bleeding, varices without bleeding, peptic ulcer disease, PUD documentation, NSAID-related ulcer, Helicobacter pylori infection, duodenal ulcer, peptic ulcer, esophageal ulcer, Barrett’s esophagus, gastrojejunal ulcer, complicated peptic ulcer disease, uncomplicated peptic ulcer disease, digestive ulcer documentation, acute ulcer documentation, chronic ulcer documentation, ulcer hemorrhage, acute blood loss anemia, ulcer perforation, peritonitis, ulcer obstruction, esophageal ulcer site, gastric ulcer site, duodenal ulcer site, peptic ulcer site, gastrojejunal ulcer site, gastrointestinal obstruction, intestinal obstruction documentation, small bowel obstruction, obstruction etiology, obstruction due to neoplasm, obstruction due to Crohn’s disease, constipation versus fecal impaction, fecal impaction documentation, volvulus documentation, enterostenosis documentation, bowel stricture documentation, surgical consult for obstruction, postoperative ileus, post-op ileus documentation, ileus complication query, expected postoperative ileus, inherent postoperative ileus, true postoperative ileus complication, abdominal x-ray, NG tube placement, NGT placement, TPN documentation, KUB x-ray, gastroenteritis documentation, infectious gastroenteritis, viral gastroenteritis, bacterial gastroenteritis, E. coli gastroenteritis, Salmonella gastroenteritis, Norwalk virus gastroenteritis, Norovirus gastroenteritis, C. difficile gastroenteritis, noninfectious gastroenteritis, radiation gastroenteritis, drug-induced gastroenteritis, allergic gastroenteritis, food hypersensitivity gastroenteritis, Clostridioides difficile, C. difficile infection, C. difficile enterocolitis, recurrent C. difficile infection, antibiotic-associated C. difficile, clindamycin, cephalosporins, penicillin, fluoroquinolones, watery diarrhea, abdominal cramping, dehydration, tachycardia, fever, leukocytosis, acute kidney injury, weight loss, loss of appetite, distended abdomen, blood in stool, pus in stool, vancomycin treatment, fidaxomicin treatment, Flagyl treatment, fecal transplant, fecal microbiota transplant, fluids, electrolytes, probiotics, sepsis due to C. difficile, bowel perforation, nutritional status, toxic megacolon, skin integrity, gastrointestinal malignancy, GI malignancy documentation, small intestine tumors, carcinomas, lymphomas, carcinoids, colon polyps, rectal polyps, precancerous polyps, biopsy documentation, malignancy versus benign diagnosis, pathology report delays, primary malignancy, secondary malignancy, anus cancer, anal canal cancer, esophageal cancer, large intestine cancer, small intestine cancer, rectal cancer, stomach cancer, colon primary malignancy, esophagus primary malignancy, stomach primary malignancy, Kaposi’s sarcoma of GI sites, pancreas secondary malignancy, malignant ascites, liver metastasis, large intestine metastasis, small intestine metastasis, focus of treatment documentation, extension of existing malignancy, neoplasm principal diagnosis, pathology review, reason for admission, direction of treatment, Barrett’s esophagus documentation, Barrett’s esophagus with dysplasia, Barrett’s esophagus without dysplasia, Barrett’s esophagus with esophageal varices, Barrett’s esophagus with ulcer, long-term GERD, esophageal cancer risk, dysphagia with Barrett’s esophagus, hernia documentation, hernia site documentation, hernia laterality, inguinal hernia documentation, femoral hernia documentation, unilateral hernia, bilateral hernia, recurrent hernia, umbilical hernia, ventral hernia, peristomal hernia, diaphragmatic hernia, abdominal hernia, hernia with gangrene, incarcerated hernia, hernia with obstruction, strangulated hernia, appendicitis documentation, acute appendicitis, gangrenous appendicitis, ruptured appendix, perforated appendix, appendicitis with abscess, appendicitis with peritonitis, localized peritonitis, generalized peritonitis, diffuse peritonitis, percutaneous abscess drainage, appendectomy, IBS documentation, IBD documentation, irritable bowel syndrome, inflammatory bowel disease, Crohn’s disease, granulomatous enteritis, granulomatous colitis, regional enteritis, ileitis, terminal ileitis, ulcerative colitis, chronic bowel inflammation, destructive inflammation, diverticulitis with bleeding, diverticulitis with perforation, diverticulitis with abscess, diverticulosis with bleeding, acute kidney injury due to dehydration, rectal bleeding documentation, fistula documentation, abscess documentation, acute blood loss anemia documentation, blood transfusion not required for acute blood loss anemia, perforation of intestine, bowel procedure mortality risk, chronic gastric ulcer with hemorrhage, acute gastric ulcer without hemorrhage or perforation, acute gastric ulcer with hemorrhage and perforation, acute hepatitis C with hepatic coma, acute hepatitis C without hepatic coma, chronic hepatitis C, alcoholic fatty liver, alcohol dependence with withdrawal, anemia unspecified, portal hypertension, Salmonella enteritis, unspecified food poisoning, nonbacterial gastroenteritis, acute posthemorrhagic anemia, acute vascular insufficiency of intestine, paralytic ileus, intestinal adhesions, partial intestinal obstruction, complete intestinal obstruction, unspecified intestinal obstruction, GI device complication, infected medical device documentation, sepsis due to infected device, G-tube infection, device complication principal diagnosis, digestive system procedures, bowel resections, resection approach documentation, resection laterality documentation, anatomical site documentation, total resection, partial resection, bowel obstruction procedure documentation, bowel perforation procedure documentation, bowel abscess procedure documentation, bowel necrosis documentation, bowel gangrene documentation, bowel neoplasm documentation, gastrointestinal resection location, esophagus resection, upper esophagus, middle esophagus, lower esophagus, stomach resection, pylorus, small intestine resection, duodenum, jejunum, ileum, ileocecal valve, large intestine resection, cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum, appendectomy approach, open appendectomy, percutaneous endoscopic appendectomy, laparoscopic converted to open procedure, hernia repair documentation, bowel reduction inherent to hernia repair, manual manipulation of bowel, torsed bowel, twisted bowel, kinked bowel, cyanotic bowel, colostomy takedown, colostomy reversal, re-anastomosis, colon trimming, colon resection documentation, lysis of adhesions, adhesiolysis documentation, significant lysis of adhesions, extensive lysis of adhesions, adhesions integral to procedure, intestinal obstruction due to adhesions, added operative time documentation, body part freed by lysis of adhesions, PEG tube, PEJ tube, esophagoscopy, colonoscopy, medical DRG procedures, tube feeding documentation, TPN diagnosis documentation, PEG tube complication, gastrostomy tube complication, mechanical gastrostomy complication, infected gastrostomy complication, small bowel vascular necrosis, appendicitis with sepsis, GI bleed query, gastritis with new blood, PRBC transfusion, pathology pending, cause-and-effect query, small bowel neoplasm, chemotherapy for small bowel neoplasm, small bowel obstruction due to neoplasm