The attached excel document, provided by ACDIS member Theresa Davis, RN, CCDS, is a complete sortable list of the FY 2010 CC and MCC lists, as well as the CC and MCC additions and deletions. These can be found in the tabs across the bottom of the page.

Attached is the fiscal year (FY) 2010 list of complications/comorbidities (CCs).

Attached is the fiscal year (FY) 2010 list of Major Complications/Comorbidities (MCCs).

The attached concurrent core measures advisory form is intended for use for CDI programs involved in core measures documentation. The form is courtesy of Melanie Halpern, RN-BC, MBA, CCDS, and St. Mary's Hospital in Passaic, NJ.

This sample heart failure query form helps physicians specify the type of heart failure through easy to use check boxes.

The attached MDC Review Checklist, provided by Deborah Dallen, RN, Clinical Documentation Coordinator for Albert Einstein Medical Center in Philadephia, is intended as a tool for a preceptor to sign off that each MDC was reviewed with the CDI specialist orientee.

The attached CDI specialist orientation checklist, provided by Deborah Dallen, RN, Clinical Documentation Coordinator for Albert Einstein Medical Center in Philadephia, is provided as a reference for getting new CDI specialists up to speed and trained.

The attached DRG Decision Tree provides a flowchart explaining how DRGs are assigned, based on V26.0 of the 3M MS-DRG Definitions Manual.

Attached is a sample palliative care query form, provided by Rush University Medical Center.

Note that this form is intended for use in the Epic electronic record. Per Rush Univeristy Medical Center:

• We add to the query any additional supporting information indicated by the record (e.g., DNR/DNI status). 
• Because we have a totally electronic record (Epic), we have educated MDs and also developed an Epic Smart Phrase to support their documentation. The Smart Phrase is:

Palliative Care/Comfort Care: Goals of care have been discussed with _____________ regarding this patient with _______________ disease. A decision [has been made/was made] to begin Palliative Care/Comfort Care starting _______________

The attached document provides a sample newsletter from the Florida ACDIS Chapter. In it, chapter president Sylvia Hoffman offers some query tips and talks about the group's upcoming events.

The attached document provides a sample query form for clarifying physician documentation of altered mental status in order to arrive at a more specific diagnosis, such as encephalopathy. The form was developed by James Kennedy, MD, CCS, of FTI Healthcare and is designed to comply with the recommendations of the American Health Information Management Association (AHIMA).

Mease Countryside and Mease Dunedin hospitals in Florida pilot-tested the evidence based measures (EBM) progress notes for their CDI physician queries. Use the progress note to capture information up front for coding as well as quality measurement purposes.

Attached is the 2009 ACDIS conference attendee list, sorted by name and organization.

Attached is the powerpoint presentation Physician documentation clarification: A coding, clinical, and patient safety perspective, as presented by Andrew Dombro, Mario Perez, and Mel Tully at the 2009 ACDIS conference.

Attached is the powerpoint presentation Challenges in critical care: Sepsis and respiratory failure, as presented by William Haik at the 2009 ACDIS conference.

Attached is the powerpoint presentation Managing a clinical documentation department to excellence, as presented by Randi Ferrare at the 2009 ACDIS conference.

Attached is the powerpoint presentation A clinical documentation program success story five years after implementation, as presented by Terry Bakowicz and Jill Dressler at the 2009 ACDIS conference.

Attached is the powerpoint presentation Understanding Medicare's quality indicators, as presented by Kristen Geissler at the 2009 ACDIS conference.

Attached is the powerpoint presentation What not to ask physicians, as presented by Robert Gold at the 2009 ACDIS conference.

Attached is the powerpoint presentation New analytics for new DRGs: Using business intelligence tools to support a measurement program for documentation and coding improvement, as presented by Dave Caplan at the 2009 ACDIS conference.

Attached is the powerpoint presentation The RAC experience: Use your CDI program to proactively address the RAC audits, as presented by Catherine O'Leary at the 2009 ACDIS conference.

Attached is the powerpoint presentation Forms and tools workshop, as presented by Gloryanne Bryant at the 2009 ACDIS conference.

Attached is the powerpoint presentation Hospitals cannot live by DRGs alone: A focus on severity of illness and risk of mortality, as presented by Tamara Hicks at the 2009 ACDIS conference.

Attached is the powerpoint presentation Teaching physicians "What's in it for me" (WIIFM), as presented by Margi Brown at the 2009 ACDIS conference.

Attached is the powerpoint presentation Renal disease, as presented by Robert Gold at the 2009 ACDIS conference.

Attached is the powerpoint presentation Restarting or revamping your CDI program: A case study, as presented by Catherine O'Leary and Colleen Garry at the 2009 ACDIS conference.

Attached is the powerpoint presentation Critical chart analysis: How and where to identify opportunities in a DRG-based CDI program, as presented by Lynne Spryszak at the 2009 ACDIS conference.

Attached is the powerpoint presentation Case study: University of Tennessee Medical Center at Knoxville, as presented by Martha Collins, Trey La Charite, Lisa Peterson, and Carla Stump at the 2009 ACDIS conference.

Attached is the powerpoint presentation Identifying the clinical "hidden agenda" in the medical record, as presented by Glenn Krauss and Gamal Eskander at the 2009 ACDIS conference.

Attached is the powerpoint presentation Things you thought you knew about ICD-9-CM coding--but may not, as presented by Shannon McCall at the 2009 ACDIS conference.

Attached is the powerpoint presentation AHIMA physician query practice brief: Maintain compliance with new guidelines, as presented by Gloryanne Bryant at the 2009 ACDIS conference.

Susan Klein, RN, director of clinical documentation management at Saint Peter’s University Hospital in New Brunswick, NJ, recently found some interesting and rewarding documentation opportunities in an area many CDI specialists overlook: the pediatric unit.

Klein shares her power point presentation regarding documentation improvement on the pediatric unit with ACDIS members.

The attached document provides a sample process for clarifying physician documentation whenever there is conflicting, ambiguous, or incomplete information in the medical record regarding any significant reportable condition or procedure.

Purpose: Complete and accurate diagnostic and procedural coded data is necessary for communication of patient's treatment plan, evaluation of the quality of care rendered, reimbursement, financial and strategic planning, outcomes and statistical analyses, epidemiology and research. Clinical Documentation Improvement professionals must continue to meet the challenges of contributing to an accurate and meaningful database that clearly defines both the patient mix and the use of resources. Assuring the accuracy of coded data is a shared responsibility between the Clinical Documentation Specialists, Health Information Management professionals and clinicians

Policy: When officially recognized coding resources do not address the question at hand, the Clinical Documentation Specialist should raise the question for discussion amongst the coders, DRG Analyst, physician advisor and/or Coding Manager, and Clinical Documentation staff members.

Purpose: To establish Clinical Documentation Improvement compliance practices. There are department policies and procedures related to the Clinical Documentation Management Program which are located in the departmental policies and procedure manual.

Scope and Purpose of Policy: To clarify physician documentation whenever there is conflicting, ambiguous, or incomplete information in the medical record regarding any significant reportable condition or procedure.

This attached documentation tip sheet is designed to be printed out and used as a pocket reference for physicians.

Training: Sample e-mail regarding physician documentation for diagnosing x-ray findings courtesy of Mike Alcorn, LVN, director of clinical documentation improvement at North Cypress (TX) Medical Center.

Training: Sample e-mail regarding physician documentation for G.I. Hemorrhage and Anemia courtesy of Mike Alcorn, LVN, director of clinical documentation improvement at North Cypress (TX) Medical Center.

Training: Sample e-mail regarding physician documentation for history of CVA vs. late effects that can be coded courtesy of Mike Alcorn, LVN, director of clinical documentation improvement at North Cypress (TX) Medical Center.

Training: Sample e-mail regarding physician documentation for chronic heart failure, drop the C for chronic and add the D for dystolic, courtesy of Mike Alcorn, LVN, director of clinical documentation improvement at North Cypress (TX) Medical Center. Effective October 1, 2007 “CHF” was removed as a comorbid condition from coding guidelines. In order for heart failure to be listed as a comorbid condition, it must be diagnosed with severity and type of heart failure.

Training: Sample e-mail regarding physician documentation for chronic heart failure courtesy of Mike Alcorn, LVN, director of clinical documentation improvement at North Cypress (TX) Medical Center. Secondary diagnosis are more important than ever before. Most chronic conditions do not increase severity. However, in the case of heart failure it does.

Training: Sample e-mail regarding physician documentation regarding cardiac/circulatory system diagnosis, courtesy of Mike Alcorn, LVN, director of clinical documentation improvement at North Cypress (TX) Medical Center.

This sample debridement documentation form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

This sample pneumonia documentation form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

This sample gastroenteritis documentation form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

This sample respiratory documentation form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

This sample pressure ulcer staging and POA status form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

This sample anemia documentation form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

This sample kidney disease documentation form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

This sample malnutrition progress note is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

This sample adult BMI documentation form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

This sample CHF progress note is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

This sample present on admission documentation form is courtesy of Julie Doy and the clinical documentation program at Mercy Medical Center in Des Moines, Iowa.

This sample contract and physician liaison job description from Robert Gold, MD, contains language you can adapt to your facility’s needs. Make sure to share these contracts with your facility attorney.

Use this form to document CDI professionals’ ongoing communications with physicians.

Use this sample to review your clinical documentation.

This job description, provided by Robert Gold, MD, of DCBA, Inc., provides a job description for a physician advisor within a CDI program.

Courtesy of Linda Haynes and the CDI program of Meridian Park Hospital, the attached CHF educational flyer can be printed out and posted in physician lounges, lunch rooms, dictation areas, and the like.

Courtesy of Linda Haynes and the CDI program of Meridian Park Hospital, the attached documentation improvement tips flyer can be printed out and posted in physician lounges, lunch rooms, dictation areas, and the like.

Courtesy of Linda Haynes and the CDI program of Meridian Park Hospital, the attached CHF educational flyer can be printed out and posted in physician lounges, lunch rooms, dictation areas, and the like.

This pneumonia pocket guide, provided by Gloryanne Bryant, RHIA, RHIT, CCS, corporate director of Coding/HIM Compliance for Catholic Healthcare West, is designed to help physicians document the important aspects of pneumonia in order to comply with Medicare and other regulatory standards. Note that this is a proprietary business document and is meant as an example for developing your own forms.

The attached anemia query form is courtesy of Lakeland Regional Medical Center. It was developed by a team consisting of four clinical documentation specialists, the CDI program manager, a physician advisor, and supervisor of the inpatient coding department. 

The attached CKD query form is courtesy of Lakeland Regional Medical Center. It was developed by a team consisting of four clinical documentation specialists, the CDI program manager, a physician advisor, and supervisor of the inpatient coding department. 

The attached CHF query form is courtesy of Lakeland Regional Medical Center. It was developed by a team consisting of four clinical documentation specialists, the CDI program manager, a physician advisor, and supervisor of the inpatient coding department. 

Attached is a sample combined job description/performance evaluation for a clinical documenation specialist.

ACDIS members who are thinking about starting a regional gathering of like-minded professionals may want to consider using this attached form to learn more about each other. This basic informational form asks meeting attendees for their name and contact information as well as any ideas for potential speaker topics. Feel free to download it and adapt it to your needs.

Courtesy of Shane Catalano, RN, CDI consultant with DCBA, Inc., attached is a comprehensive list of the 2009 major complications/comorbidities, arranged logically as well as alphabetically for ease of use.

Attached is a sample query form for obtaining more specific documentation on sepsis, as provided by Wendy Dougherty of Mercy Medical Center in Nampa, ID.

Attached is a sample query form for obtaining more specific documentation on chronic kidney disease, as provided by Wendy Dougherty of Mercy Medical Center in Nampa, ID.

Attached is a sample query form for obtaining more specific documentation on congestive heart failure, as provided by Wendy Dougherty of Mercy Medical Center in Nampa, ID.

Attached is a tip card to help clinical documentation specialists capture major complications/comorbidities, as provided by Amanda Suggs of Roper St. Francis hospital. She notes that it should be shrunken to pocket size and laminated front and back to serve as a pocket guide.

Attached is a sample physician documentation tip sheet for the new fiscal year 2009 ICD-9-CM fever codes, courtesy of Gloryanne Bryant of Catholic Healthcare West.

Attached is a sample documentation clarification worksheet for respiratory symptoms, to assist physicians with documentation of acute respiratory failure when appropriate.

Attached is a job description for a physician liaison/physician champion position, as submitted by Gloryanne Bryant of Catholic Healthcare West.

Attached is the attendee list of the 2008 ACDIS annual conference, sorted by name and organization.

Attached is the powerpoint presentation The Coding/Clinical Documentation Link, as presented by Heather Taillon at the 2008 ACDIS conference.

Attached is the powerpoint presentation Case Study: Kindred Healthcare LTAC Hospital System, as presented by Pam Lovell and Wendy De Vregud at the 2008 ACDIS conference.

Attached is the powerpoint presentation Case Study: Clarian Health Partners, Indianapolis, Developing and Implementing a CDI Program in a Multifacility, Academic, Level 1 Trauma Center, as presented by Marijane Armbruster and Lena Wilson at the 2008 ACDIS conference.

Attached is the powerpoint presentation Data Mining and Reporting, as presented by Colleen Garry at the 2008 ACDIS conference.

Attached is the powerpoint presentation Building Physician Relationships, as presented by Robert Gold at the 2008 ACDIS conference.

Attached is the powerpoint presentation Physician Queries and Communication--Medical University of South Carolina Case Study, as presented by Pam Parris and Jacqueline Robinson at the 2008 ACDIS conference.

Attached is the powerpoint presentation Heart Failure, as presented by Robert Gold at the 2008 ACDIS conference.

Attached is the powerpoint presentation Case Study: Roper St. Francis, as presented by Jean Clark at the 2008 ACDIS conference.

Attached is the powerpoint presentation Present on Admission, as presented by Shannon McCall at the 2008 ACDIS conference.

Attached are the powerpoint slides for Physician Queries and Compliance, a session presented by Gloryanne Bryant at the 2008 ACDIS conference.

Attached is the powerpoint presentation Medicare Severity DRGs (MS-DRGs), as presented by Gloryanne Bryant at the 2008 ACDIS conference.

The attached document provides a sample query form to help specify types of pneumonia.

This attached form is a tip card for CDI specialists to help them reference common major complications/comorbidities (MCCs). It is not a comprehensive list.

This sample form is intended to be posted in physician dictation areas in order to educate physicians on documentation requirements under MS-DRGs.

This attached document provides sample policy guidelines for coding complications.

The attached document provides a sample job description of a CDI manager who oversees a CDI department.

This attached diagnosis specificity policy offers guidelines for coding conditions with nonspecific and specific terms.

Attached is a sample form to assist with backend communication between coders and clinical documentation specialists.

The attached form provides a sample policy on establishing lines of communication between auditors, clinical documentation specialists, and remote coding staff.

Attached is a sample wound debridement query form.

The attached form includes categories and codes exempt from the Present on Admission (POA) requirement.

Attached is a sample coding diagnosis clarification sheet.

Attached is a sample clinical documentation specialist job description.

This form, provided by Dawn Diven, BSN, RN, documentation specialist for Western Maryland Health System in Cumberland, MD, is a sample documentation form for physicians to confirm wound assessments and descriptions by nursing staff. As the nurse files the history and physical it is generated and placed into the physician's progress notes to sign. This report is from a chart and is not ready to use, but is proivded here as an example for other hospitals to consider.

This form, provided by Gloryanne Bryant, RHIA, CCS, senior director of corporate coding/HIM compliance for Catholic Healthcare West in San Francisco, CA, is a template to query physicians regarding the type of debridement they have performed (excisional vs. non-excisional). Note that this is a proprietary business document and information on reprint permission may be found at the bottom of the form.

This sample chart, provided by Wendy De Vreugd, senior director of case management, west group, for Kindred Healthcare, provides an excel spreadsheet for tracking the impact a clinical documentation improvement specialist can have on a hospital’s case-mix index. See "Key to sample clinical documentation improvement chart" for an explanation of its use.

This document, provided by Wendy De Vreugd, senior director of case management, west group, for Kindred Healthcare, provides an explanation of the sample clinical documentation improvement spreadsheet above.

This job description, provided by Tamara Hicks of North Carolina Baptist Hospital, provides a sample job summary, primary accountabilities, and job specifications of a clinical documentation specialist.

Clinical documentation manager job description

This attachment, provided by William E. Haik, MD, of DRG Review, Inc., is a sample job description of a clinical documentation improvement specialist.

Following is a complete 2008 complication/comorbidity list.

Following is a complete 2008 major complication/comorbidity list, arranged alphabetically.

This attached form, provided by Gloryanne Bryant, corporate director of coding/HIM compliance for Catholic Healthcare West, helps clinical documentation improvement specialists clarify for simple vs. complex pneumonia.

This attached form, provided by Gloryanne Bryant, corporate director of coding/HIM compliance for Catholic Healthcare West, helps clinical documentation improvement specialists query for specific types of diabetes.

This document provides a complete listing of all the complications/comorbidities (CCs) and major complications/comorbidities under the new Medicare Severity DRG system. It is broken out by ICD-9 and V code and includes a list of all the previous CCs under the former CMS-DRG system.

The attached sample query form is designed to help physicians better document a patient’s degree of malnutrition.

This form provides one facility's "gold standard" of what clinical documentation improvement specialists should strive for in order to ensure accurate, complete, physician documentation in the record.

Attached is a sample query form designed to help physicians better document abnormal tests in the record.

Attached is a sample physician query form designed to help clarify urosepsis vs. septicemia in the record.

Attached is a sample physician query form designed to clarify clinical evidence of sepsis in the medical record.

Attached is a heart failure chart designed to help clinical documentation improvement specialists identify signs and symptoms of heart failure in the medical record.

Attached is a sample chronic kidney disease (CKD) physician query form designed to help physicians properly document the stage of a patient's CKD.

Attached is a sample query form designed to help physicians properly document any diagnoses that are present on admission.