| 30 Day Readmit | Optional add-on to indicate if the patient has been readmitted within 30 days of the admit date. This field will populate with the previous account number and can be used for reporting. |
| Admit Reason | The reason registration typed in, not the admit reason set by the coder. |
| Assigned | The code was used for billing purposes. If you are looking for codes that are suggested or added by CDI for working/baseline purposes you would use the document code. Note: If designing workflow it is recommended this field is used for CDI, but for QA purposes its recommended that‘Assigned’ is used to ensure you are QA on what was billed vs what was suggested. |
| Baseline | The baseline data of the chart that would have been coded and billed without the intervention of CDI staff. This data is used to measure the impact that CDI has on a patient’s chart is then measured as the difference between the Baseline DRG and the Billed DRG (either the weights or the reimbursement). |
| Category | A category is a “Dolbey” created field used to further specify a patient type, if applicable. At some sites, category might equal patient type while others may have a category that is comprised of multiple fields to create that category. For example, if you would like to report on how many charts a coder completed for inpatient and then define them by LOS, you then have a category to define the difference between LOS patient types or service lines. |
| Document Code | Any code on a chart, manually entered or suggested. The code can be unassigned which means it’s not used for billing or assigned which is used for billing. Note: If designing workflow it is recommended this field is used for CDI, but for A purposes it’s recommended that ‘Assigned’ is used to ensure you are QA on what was billed vs what was suggested. |
| Document Type | The document(s) that are present on the patient account. The document types for searching and/workflow are required to have the interface name, not the friendly name. If you do not know the document names that are available to use, Dolbey can provide a table which provides this information. Send an email to results@dolbey.com requesting the document table names. |
| DRG Reconciled? | Reconciliation typically refers to a process that occurs when the working and final DRG’s do not match. Charts get flagged with a field called ‘Is DRG reconciled’. If there is a check mark, then the chart has been reviewed and the chart has been reconciled either as an agree to disagree or agree and an adjustment is made to the working or final DRG once CDI and/or Coding does another review. |
| Final | Coded data added to the chart be billed out. |
| Next Review Date | Next review date is set either automatically by the system or manually by the CDI user if they choose to override the system automatic default date. The default date is whatever your management team has selected as a default interval for follow up reviews to occur. This may mean that the default is set for the next business day or two days later. This field is can be manually overridden by a CDS in the Code Summary viewer. Why would a CDS manually override this field? If you have reviewed the chart and know the patient is going to have surgery in a few days and there is no reason for a follow up review based on your sites policy’s. You may choose to augment the next review date for after the scheduled surgery. |
| Physician Query Open | The number of physician queries on the account that have not been closed. A physician response could have been received, but if it hasn’t been viewed by a user within CAC, the physician query is still considered “open”. |
| Physician Query Total | The number of queries on a chart, regardless of whether the queries are opened or closed. If a user was in an account that had an open physician query, and an external interface closed that query, the query total on the account is updated upon closing the account. |
| Reconciliation | A process that occurs when the working and final DRG’s do not match. Charts get flagged with a field called ‘Is DRG reconciled’. If there is a check mark then the chart has been reviewed and the chart has been reconciled either as an agree to disagree or agree and an adjustment is made to the working or final DRG once CDI and/or Coding does another review. |
| Workgroup | A list of charts to be completed for coding, CDI or QA. Most charts flow into a Workgroup based upon automatic criteria, however admin user can route a chart to Workgroup (uncommon). |
| Working | The working information due to the intervention of the CDI staff. The CDI staff will update this information concurrently until the patient is discharged with additional data surrounding presenting problems or provisional diagnosis. |