Health Information Management

Health Information Management Articles by Topic: Clinical Documentation Improvement

News: Conference poster presentations offer education on common CDI concerns

  • CDI Strategies, Issue 11, May 16, 2013

    This year’s conference features 26 poster presentations on a range of pressing topics...

News: Updated editions of ICD-10 and physician queries’ handbooks released; authors to sign copies in the exhibit hall

  • CDI Strategies, Issue 11, May 16, 2013

    A number of new CDI materials will be available at the HCPro booth (unless noted) throughout the...

Tips: Advice from previous conference attendees/CDI Talk network

  • CDI Strategies, Issue 11, May 16, 2013

    Editor’s Note: The following tips were adapted from comments by previous ACDIS attendees and...

Tip: Don't miss the following Nashville must-see tourist sites

  • CDI Strategies, Issue 11, May 16, 2013

    There's a lot to do in Nashville. First and foremost, when you think of Nashville you think of...

Q&A: Nashville Conference Buzz

  • CDI Strategies, Issue 11, May 16, 2013

    Editor’s Note: Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, MCP, presents “Integrating CDI...

Membership Updates: Update your ACDIS contact information; renew your membership now

  • CDI Strategies, Issue 11, May 16, 2013

    Last week’s ACDIS Quarterly Conference Call hosted 372 participants and featured special...

Director’s Note: Looking forward to 6th Annual ACDIS Conference

  • CDI Strategies, Issue 11, May 16, 2013

    It is hard to believe that the 6th Annual ACDIS Conference is upon us. ACDIS staff will be flying...

News: Listen to live podcasts, 'Talk Ten Tuesday' from ACDIS 2013

  • CDI Strategies, Issue 11, May 16, 2013

    Can’t make it to the 6th Annual ACDIS conference? Listen in to a series of broadcasts by...

Local Chapter Events: More meetings slated for May, June

  • CDI Strategies, Issue 10, May 9, 2013

    Houston, Texas: Harris Health System hosts the next meeting, Thursday, May 9, at 3 p.m. in the...

News: CMS releases data regarding hospital charges for common inpatient services

  • CDI Strategies, Issue 10, May 9, 2013

    New data released today show significant variation across the country and within communities in...

Tip: Pediatric CDI expansion may be easy as 1, 2, 3

  • CDI Strategies, Issue 10, May 9, 2013

    If you are considering expanding your CDI program to include review of pediatric records, consider...

Director’s Note: ACDIS Quarterly Conference Call today

  • CDI Strategies, Issue 10, May 9, 2013

    ACDIS members are invited to participate in a Quarterly Conference Call taking place today...

Membership Update: Items added to the Forms & Tools Library

  • CDI Strategies, Issue 10, May 9, 2013

    A number of items have recently been added to the ACDIS Forms & Tools Library. If you have...

Director’s Note: Deadline for paper-and-pencil CCDS exam today

  • CDI Strategies, Issue 9, April 25, 2013

    More than 1,000 CDI professionals now hold the Certified Clinical Documentation Specialist (CCDS...

Membership Update: Quarterly Conference Call scheduled for May 9

  • CDI Strategies, Issue 9, April 25, 2013

    Our next quarterly conference call is scheduled for Thursday, May 9, 1-2 p.m. To access the call...

Local Chapter Events: Meetings slated for May, June

  • CDI Strategies, Issue 9, April 25, 2013

    The following ACDIS local chapters have meetings coming up in May and the beginning of June. If you...

News: Don't look for one size fits all ICD-10 fix

  • CDI Strategies, Issue 9, April 25, 2013

    Here is a statistic that will come as no surprise to most coders and CDI professionals...

Tip: Free webinar offered regarding incorporating technology in CDI practices: Register today

  • CDI Strategies, Issue 9, April 25, 2013

    OptumInsight and ACDIS host a free webinar on June 5, 1-2 p.m., ET, “Technology Innovations...

Q&A: Query options for lack of clinical indicators

  • CDI Strategies, Issue 9, April 25, 2013

    Q: The physician documented mild bronchitis treated with Zithromax in the progress note on day two...

Tip: Improve Physician Profiles through SOI/ROM documentation

  • CDI Strategies, Issue 9, April 25, 2013

    Tip: Improve Physician Profiles through SOI/ROM documentation

Q&A: Defining roles for physician advisor/champion

  • CDI Strategies, Issue 8, April 11, 2013

    Q: Is it true that a CDI physician advisor/champion cannot be a direct patient care provider? A...

Director’s Note: Are you ready for Nashville?

  • CDI Strategies, Issue 8, April 11, 2013

    My heart is already warming to thoughts of Nashville in springtime, the site of our 6th annual...

Membership Update: Quarterly CDI Journal released

  • CDI Strategies, Issue 8, April 11, 2013

    The April 2013 edition of the CDI Journal was released last week. It not only includes the latest...

Local Chapter Events: More meetings scheduled for April's end

  • CDI Strategies, Issue 8, April 11, 2013

    There are more than 40 local ACDIS chapters across the country. They range in formality but...

News: Recovery Auditors continue medical necessity reviews

  • CDI Strategies, Issue 8, April 11, 2013

    Medical necessity for cardiovascular procedures is the top overpayment issue for three out of the...

News: OIG targets mechanical ventilation

  • CDI Strategies, Issue 8, April 11, 2013

    The OIG is taking a closer look at mechanical ventilation, according to its FY 2013 Work Plan. In...

Q&A: Staffing preparation for ICD-10

  • CDI Strategies, Issue 7, March 28, 2013

    Q: How are staffing needs expected to change in relationship to ICD-10? A: I’m not aware of...

Director’s Note: Conference hotel sold out, nearby options available

  • CDI Strategies, Issue 7, March 28, 2013

    The Renaissance Nashville Hotel—site of the ACDIS 6th Annual Conference--has sold out...

Local Chapter events: April meetings offer networking opportunities

  • CDI Strategies, Issue 7, March 28, 2013

    The following ACDIS local chapters have meetings coming up in April. If you are interested in...

News: Validity of hospital and physician report cards called into question

  • CDI Strategies, Issue 7, March 28, 2013

    The Leapfrog Group. Healthgrades. The Joint Commission. U.S. News and World Report. Consumer...

News: CMS releases new guidance for rebilling necessity denials

  • CDI Strategies, Issue 7, March 28, 2013

    It was hardly explicit that organizations could rebill on an outpatient basis (or fully bill) for...

News: CMS begins ICD-10 translation of NCDs, hosts preparation calls

  • CDI Strategies, Issue 7, March 28, 2013

    In order to meet the ICD-10 October 1, 2014, implementation timeline, CMS began making necessary...

News: N.C. Blue Cross Blue Shield bundles knee replacement payments

  • CDI Strategies, Issue 7, March 28, 2013

    Blue Cross Blue Shield (BCBS) of North Carolina represents the latest payer to join the bundled...

Director's Note: Are you planning take the CCDS exam at the ACDIS conference in Nashville?

  • CDI Strategies, Issue 6, March 14, 2013

    The annual paper and pencil seating of the Certified Clinical Documentation Specialist (CCDS) exam...

Membership Update: New membership option, sponsor webpage, ICD-10 education offerings

  • CDI Strategies, Issue 6, March 14, 2013

    A new platinum-level ACDIS membership package includes a choice of one of two popular audio...

Take our Physician Query Survey

  • CDI Strategies, Issue 6, March 14, 2013

    In light of the most recent physician query practice guidance released in the February edition of...

Local Chapter Events: Meetings for March and April

  • CDI Strategies, Issue 6, March 14, 2013

    West Virginia: Meets on Wednesday, March 20, 2 p.m. at Charleston Area Medical Center to discuss...

News: Recovery Auditor activity intensifying

  • CDI Strategies, Issue 6, March 14, 2013

    Recovery auditor recoupments increased 14% since 2012, according to the 2013 Recovery Auditor...

News: CMS delays meaningful use rulemaking, stands firm on ICD-10 implementation date

  • CDI Strategies, Issue 6, March 14, 2013

    Rulemaking regarding Stage 3 meaningful use of electronic health records will be delayed until...

Q&A: Multiple choice options on query templates

  • CDI Strategies, Issue 6, March 14, 2013

    Q: Our CDI department is developing clarification forms and I have voiced concern with some of the...

News: CMS offers ICD-10 Update session

  • CDI Strategies, Issue 5, February 28, 2013

    News: CMS offers ICD-10 Update session

News: Physician query benchmarking survey opens

  • CDI Strategies, Issue 5, February 28, 2013

    Please take a few minutes to participate in this 35-question survey. It asks for input regarding...

Tip: Ensure malnutrition documentation and coding meet current clinical standards

  • CDI Strategies, Issue 5, February 28, 2013

    New guidelines published in the May 2012 Journal of the Academy of Nutrition and Dietetics...

Q&A: Using case-mix index to track CDI efforts

  • CDI Strategies, Issue 5, February 28, 2013

    Q: Our case-mix index (CMI) seems to be dropping and management is putting pressure on the CDI...

Director's Note: Volunteers for CDI Week planning committee sought

  • CDI Strategies, Issue 5, February 28, 2013

    The third annual CDI Week takes place on September 16-20, 2013. ACDIS is looking for several...

Membership Update: Quarterly Conference Call posted for members

  • CDI Strategies, Issue 5, February 28, 2013

    The ACDIS quarterly conference call of Thursday, February 14, is now available for download...

Local Chapter Update/Events: New Leadership Toolkit released

  • CDI Strategies, Issue 5, February 28, 2013

    During the February conference call, ACDIS unveiled its new “Leadership Toolkit” which...

Membership update: Quarterly Conference Call Thursday focuses on ICD-10

  • CDI Strategies, Issue 4, February 14, 2013

    The next quarterly conference call is scheduled for today, Thursday, February 14, 1-2 p.m. ET. To...

News: Latest Recovery Auditor report sent to Congress

  • CDI Strategies, Issue 4, February 14, 2013

    Recovery Auditors (previously called Recovery Audit Contractors [RAC]) saved Medicare nearly $500...

News: Bundled payment initiatives begin testing phase

  • CDI Strategies, Issue 4, February 14, 2013

    More than 500 organizations have signed on to participate in CMS’ “Bundled Payments for...

Q&A: Capture clinical indicators in the medical record

  • CDI Strategies, Issue 4, February 14, 2013

    Q: We recently had a case where the patient was admitted from the ED with pneumonia but the...

Director’s Note: ACDIS members elect four new Advisory Board members

  • CDI Strategies, Issue 4, February 14, 2013

    ACDIS members recently elected four new board members in a popular vote of 10 finalists . (Read...

News: ACDIS/AHIMA query brief released

  • CDI Strategies, Issue 4, February 14, 2013

    After several months of effort, AHIMA released "Guidelines for Achieving a Compliant Query...

Tip: Ask these questions to kickstart your ICD-10 prep, planning

  • CDI Strategies, Issue 3, January 31, 2013

    When preparing your ICD-10 training schedule, use these questions to develop a baseline:

Q&A: Are query headings permissible?

  • CDI Strategies, Issue 3, January 31, 2013

    Q: I was under the impression that headings on a query form are leading.  Can you help me with...

Membership update: Please take our brief three-question benchmarking survey

  • CDI Strategies, Issue 3, January 31, 2013

    We know many of you rely on ACDIS national benchmarking survey data to compare yourself against...

Conference update: Professional of the year nominations due Feb. 8, poster application deadline extended to Feb. 15

  • CDI Strategies, Issue 3, January 31, 2013

    ACDIS will award the CDI Professional of the Year and two winners of Recognition of CDI...

News: Big data dives set to highlight the importance of medical record clarity

  • CDI Strategies, Issue 3, January 31, 2013

    On January 15, UnitedHealth Group Inc. and Mayo Clinic announced a new joint venture dubbed Optum...

News: January sees 106 ACOs begin operation

  • CDI Strategies, Issue 2, January 17, 2013

    Across the country, 106 new Medicare Shared Savings Program Accountable Care Organizations (ACOs...

News: New York health system plots pay-for-performance initiative

  • CDI Strategies, Issue 2, January 17, 2013

    New York City’s Health and Hospitals Corporation represents the nation’s largest public...

Director’s Note: Conference lineup set; poster applications and CDI Professional of the Year nominations sought

  • CDI Strategies, Issue 2, January 17, 2013

    This year’s ACDIS Conference takes place May 21–23, 2013 at the Renaissance Nashville...

Membership update: CDI Journal released

  • CDI Strategies, Issue 2, January 17, 2013

    ACDIS Membership update: CDI Journal released

Q&A: Measuring CDI specialist productivity

  • CDI Strategies, Issue 2, January 17, 2013

    Q: Our CDI program is three years old and our administration still questions our productivity...

ICD-10 and Recovery Auditor Benchmarking reports: Please take these surveys today

  • CDI Strategies, Issue 2, January 17, 2013

    To obtain data regarding CDI program involvement in ICD-10 preparations, ACDIS composed a...

News: New York to impose sepsis treatment criteria

  • CDI Strategies, Issue 2, January 17, 2013

    New York could become the first state to draft comprehensive measures regarding the identification...

News: New York to impose sepsis treatment criteria

  • CDI Strategies, Issue 2, January 17, 2013

    New York could become the first state to draft comprehensive measures regarding the identification...

News: Healthcare leadership survey identifies 2013 priorities

  • CDI Strategies, Issue 2, January 17, 2013

    Improving patient experience and satisfaction topped the list of healthcare leadership priorities...

Tip: Assess current documentation before discussing ICD-10 with physicians

  • APCs Insider, Issue 1, January 4, 2013

    Avoid taking too broad an approach when discussing ICD-10 documentation requirements with...

Q&A: Obtaining clarification for Schatzki’s Ring

  • CDI Strategies, Issue 1, January 3, 2013

    Q: A few times I have seen physicians document Schatzki’s Ring. I understand that if the...

Director’s Note: Happy New Year

  • CDI Strategies, Issue 1, January 3, 2013

    “For last year’s words belong to last year’s language. Next year’s words...

Membership Update: Video training on ACDIS membership benefits available

  • CDI Strategies, Issue 1, January 3, 2013

    In the fall, ACDIS Associate Director Melissa Varnavas walked members through a free webinar...

News: GAO reports indicate CMS/HHS needs better oversight

  • CDI Strategies, Issue 1, January 3, 2013

    A November report from the Government Accountability Office (GAO) calls on CMS to provide better...

Tip: Take care sequencing diagnoses

  • CDI Strategies, Issue 1, January 3, 2013

    Depending on how they are sequenced, CC and MCC conditions can have a direct effect on MS-DRG...

Tip: Establish a game plan for ICD-10 queries

  • CDI Strategies, Issue 27, December 20, 2012

    ICD-10-CM/PCS incorporates laterality, acuity, anatomical specificity, and a slew of additional...

Q&A: Use of E codes in reporting postoperative complications

  • CDI Strategies, Issue 27, December 20, 2012

    Q: Can you clarify the requirements surrounding the use of E codes? We have been working on...

Director’s Note: ICD-10 Benchmarking survey open

  • CDI Strategies, Issue 27, December 20, 2012

    When the first ACDIS ICD-10 implementation benchmarking survey published in October of 2010, there...

Membership update: Forms & Tools Library items added, revised library forthcoming

  • CDI Strategies, Issue 27, December 20, 2012

    For more than six months, a number of dedicated volunteers have pored over the the ACDIS Forms...

News: Medical necessity battle continues; AHA says lawsuit requires urgent attention

  • CDI Strategies, Issue 27, December 20, 2012

    The fight over medical necessity continued last week as the American Hospital Association and its...

Tip: CDI growth depends on record review expansion

  • CDI Strategies, Issue 26, December 6, 2012

    By Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS In a recent CDI Talk conversation the...

Q&A: Syncope due to UTI

  • CDI Strategies, Issue 25, December 6, 2012

    Q:  A patient with a long history of Type I diabetes is admitted after a syncope episode...

Director's Note: Advisory board nomination committee evaluating new applicants; vote in January

  • CDI Strategies, Issue 26, December 6, 2012

    The nomination period for the ACDIS advisory board recently closed, and a nomination committee has...

Membership Update: ICD-10 Survey launched; November Conference Call posted; upcoming local meetings announced

  • CDI Strategies, Issue 26, December 6, 2012

    ICD-10 Survey: Please take a moment to participate in the 2012 CDI Specialist’s ICD-10...

News: AMA continues its opposition to ICD-10

  • CDI Strategies, Issue 26, December 6, 2012

    During its November House of Delegates meeting in Honolulu, members of the American Medical...

News: Two new reports show little impact from POA reporting

  • CDI Strategies, Issue 26, December 6, 2012

    When CMS stopped paying for healthcare-associated infections such as catheter-associated blood...

News: BayCare Health settles fraud allegations

  • CDI Strategies, Issue 26, December 6, 2012

    More than $10 million: That’s what Florida-based BayCare Health System agreed to pay the...

Tip: Take advantage of CMS tips for ICD-10 prep

  • CDI Strategies, Issue 24, November 21, 2012

    Earlier this month, CMS released a quick tip sheet “Communicating with your Payers about...

Director’s Note: Obtain CCDS CEU credit for ACDIS Quarterly Conference Call

  • CDI Strategies, Issue 24, November 21, 2012

    ACDIS is pleased to provide one CEU towards recertification of the Certified Clinical Documentation...

Tip: Use IPPS data to benchmark your CDI program

  • CDI Strategies, Issue 24, November 21, 2012

    By Don Butler, RN, BSN During a recent CDI Talk conversation, I alluded to data available in the...

Q&A: Determining what constitutes a leading query

  • CDI Strategies, Issue 23, November 8, 2012

    Q: What are the ramifications of leading queries? Who is monitoring whether a query is leading? A...

Director's Note: ACDIS collecting 'Super Star' stories

  • CDI Strategies, Issue 23, November 8, 2012

    ACDIS Members Services Specialist Penny Richards is soliciting tips and advice from the ACDIS...

Membership Update: Journal quiz posted, conference call scheduled

  • CDI Strategies, Issue 23, November 8, 2012

    The next ACDIS Quarterly Conference Call is scheduled for Thursday, November 15, from 1-2 p.m., ET...

Reminder: Nominations open for Advisory Board positions; deadline Nov. 19

  • CDI Strategies, Issue 23, November 8, 2012

    ACDIS currently seeks four new members to join its advisory board in 2013. ACDIS advisors are...

Local meetings: Nine events scheduled in November

  • CDI Strategies, Issue 23, November 8, 2012

    CDI networking efforts have grown since ACDIS’ inception to nearly 40 local chapters across...

News: Recovery Auditors on the hot seat: Suit filed against HHS

  • CDI Strategies, Issue 23, November 8, 2012

    On October 16, Representative Sam Graves (R-MO) introduced legislation to reform Recovery...

Tip: Stay on top of post-op pain coding

  • CDI Strategies, Issue 23, November 8, 2012

    ICD-9 guidelines indicate that coders should not report routine or expected postoperative pain that...

Q&A: Should cystic fibrosis always be first-listed diagnosis

  • CDI Strategies, Issue 22, October 25, 2012

    Q: I have heard that there is an AHA Coding Clinic for ICD-9-CM, which states that the exacerbation...

Director’s Note: Nominations open for Advisory Board positions

  • CDI Strategies, Issue 22, October 25, 2012

    ACDIS currently seeks four new members to join its advisory board in 2013. ACDIS advisors are...

Membership Update: ACDIS membership tour; Quarterly Conference Call scheduled

  • CDI Strategies, Issue 22, October 25, 2012

    Join ACDIS Associate Director Melissa Varnavas, CPC, on Wednesday, November 7, 1 p.m., ET, for a...

News: AHA supports bill to amend healthcare auditing programs

  • CDI Strategies, Issue 22, October 25, 2012

    A bill, introduced October 16, aims to curtail the proliferation of healthcare audits and medical...

News: Reductions in surgical complications cost hospitals

  • CDI Strategies, Issue 22, October 25, 2012

    Hospitals stand to lose about $1.2 million in annual reimbursement revenue for each 1% drop in its...

Tip: CMS offers information on preparing physicians for ICD-10

  • CDI Strategies, Issue 22, October 25, 2012

    Getting physicians on board with the transition to ICD-10 won’t be easy, but CMS is trying to...

Tip: White Paper available on principal diagnosis selection

  • CDI Strategies, Issue 22, October 25, 2012

    A clear understanding of the definition of principal diagnosis and the factors that play into...

Tip: CMS releases ICD-10 planning tips

  • CDI Strategies, Issue 21, October 11, 2012

    CMS recently released the following ICD-10 planning tips in an ICD-10 Industry Email...

Director’s Note: Seeking CDI specialists from Critical Access Hospitals

  • CDI Strategies, Issue 21, October 11, 2012

    ACDIS has received several queries regarding networking opportunities for CDI professionals working...

Membership Update: Conference planning underway; October meetings offered; new materials posted

  • CDI Strategies, Issue 21, October 11, 2012

    Conference Speaker Application Period Closed: More than 130 applications were received. The 2013...

News: CMS says more than $700 million in improper payments corrected

  • CDI Strategies, Issue 21, October 11, 2012

    Following the close of each fiscal year (FY) quarter, CMS releases statistics for the amount of...

News: OIG Work Plan targets review of MS-DRG system, contractor efforts

  • CDI Strategies, Issue 21, October 11, 2012

    Every October, the Office of Inspector General (OIG) releases its Work Plan for the upcoming fiscal...

Medicare Compliance Forum 2012 spotlight: CMS’ proposal to redefine inpatient

  • CDI Strategies, Issue 21, October 11, 2012

    In the recently released 2013 OPPS proposed rule, CMS issued a request for comments that suggests...

News: No cost savings associated with ACO demonstration, study says

  • CDI Strategies, Issue 21, October 11, 2012

    Although Accountable Care Organizations (ACO) showed an improvement in the quality and performance...

News: AHIMA calls for improved health information governance to unify standards for EHR use

  • CDI Strategies, Issue 21, October 11, 2012

    During its 84th national convention, AHIMA called for improved governance for health information to...

HIM professionals should consider a career in CDI

  • JustCoding News: Inpatient, Issue 41, October 10, 2012

    The HIM profession is constantly changing, but HIM professionals are still responsible for...

News: AHA's Coding Clinic offers clarification on 'sepsis syndrome'

  • CDI Strategies, Issue 20, September 27, 2012

    When the term ‘sepsis syndrome’ is documented coders and CDI specialists have to query...

News: Preparation advice, tools for ICD-10-CM/PCS available from CMS

  • CDI Strategies, Issue 20, September 27, 2012

    Since the release of the new ICD-10-CM/PCS implementation date, CMS has been busy publishing a slew...

Q&A: Clarification for encephalopathy

  • CDI Strategies, Issue 20, September 27, 2012

    Q:  I need further clarification regarding documentation of toxic metabolic encephalopathy...

Director’s Note: Speaker applications due this Friday, Sept. 28

  • CDI Strategies, Issue 20, September 27, 2012

    ACDIS is currently seeking speakers to present at the 2013 ACDIS sixth Annual Conference, to be...

Membership update: 2nd Annual CDI Week successes

  • CDI Strategies, Issue 20, September 27, 2012

    During the 2nd Annual CDI Week held September 17-21, facilities all over the country celebrated the...

News: CMS warns hospital associations against EHR-related fraud

  • CDI Strategies, Issue 20, September 27, 2012

    In a terse exchange of communication and reports this week, the HHS and American Hospital...

News: Noridian issues reminder regarding selection of appropriate principal diagnosis

  • CDI Strategies, Issue 19, September 13, 2012

    The terms “admitting” diagnosis and “principal” diagnosis are not...

Tip: Take seven steps to maintain CDI program success

  • CDI Strategies, Issue 19, September 13, 2012

    By Karen Newhouser, RN, BSN, CCM, CCDS In thinking about all the initiatives swirling around the...

Q&A: Conducting a health record review

  • CDI Strategies, Issue 19, September 13, 2012

    Can you provide a novice CDI professional with some tips on where to start with a record...

News: IOM report says technology can reduce healthcare costs

  • CDI Strategies, Issue 19, September 13, 2012

    Increasing the adoption of health information technology could help make healthcare delivery more...

Director’s Note: Call for speakers for the 2013 ACDIS Conference in Nashville

  • CDI Strategies, Issue 19, September 13, 2012

    ACDIS seeks speakers to present at the 2013 ACDIS sixth Annual Conference, to be held May 21-23...

Director’s Note: Materials available for CDI Week planning

  • CDI Strategies, Issue 18, August 30, 2012

    National CDI Week celebrations will soon be here. This year’s event takes place September...

Membership update: CDI Roadmap available

  • CDI Strategies, Issue 18, August 30, 2012

    After months of dedicated effort, The Clinical Documentation Improvement (CDI) Roadmap has been...

News: Latest ACDIS quarterly conference call available for download

  • CDI Strategies, Issue 18, August 30, 2012

    The ACDIS quarterly conference call of August 16, 2012 is now available for download on the ACDIS...

Local events: Chapter leaders plan fall sessions

  • CDI Strategies, Issue 18, August 30, 2012

    Florida: Reservations for the upcoming Florida ACDIS Chapter meeting slated for Saturday, September...

News: OPPS proposal could change definition of ’inpatient;’ see free white paper published by HCPro, Inc.

  • CDI Strategies, Issue 18, August 30, 2012

    In the recently released 2013 OPPS proposed rule, CMS issued a request for comments that suggests...

News: RAC activity on the rise, says AHA survey

  • CDI Strategies, Issue 18, August 30, 2012

    RAC denials rose by 24% over the previous quarter, according to the August 22 RACTrac survey...

Q&A: MS-DRG assignment and cystic fibrosis

  • CDI Strategies, Issue 18, August 30, 2012

    Q: I was interested in further discussion about cystic fibrosis coding. I am conducting an audit on...

News: HHS sets ICD-10 implementation date at October 2014

  • CDI Strategies, Issue 18, August 30, 2012

    HHS will delay implementation of ICD-10 by one year, from October 1, 2013 to October 1, 2014. HHS...

Thorough documentation review helps ensure accurate principal diagnoses

  • HIM-HIPAA Insider, Issue 7, August 20, 2012

    Clear and consistent documentation makes a coder’s job much easier, and it improves data...

Membership Update: New chapters forming in Arizona, Austin, TX, Colorado, Houston, TX, and New York City

  • CDI Strategies, Issue 17, August 16, 2012

    The following ACDIS chapters are just getting off the ground. If you are interested in...

News: New ICD-10 compliance date expected soon

  • CDI Strategies, Issue 17, August 16, 2012

    A date for the potential ICD-10 implementation deadline may be released soon. The Office of...

News: IPPS Final Rule includes some CDI related code changes

  • CDI Strategies, Issue 17, August 16, 2012

    CMS chose not to include code 428.0 (congestive heart failure, unspecified) as a CC in the IPPS...

Q&A: Chose the right data points to prove CDI department success

  • CDI Strategies, Issue 17, August 16, 2012

    Q:  If a hospital CEO were to tell a new CDI department manager to pull together some...

Director’s Note: Do you hold the CCDS certification?

  • CDI Strategies, Issue 17, August 16, 2012

    There are now nearly 1,000 professionals who possess the Certified Clinical Documentation...

Q&A: Query for aspiration pneumonia

  • CDI Strategies, Issue 16, August 2, 2012

    Q:  A physician admitted a patient with pneumonia, which was the first listed diagnosis. The...

News: Prepayment reviews demonstration project set to begin in August

  • CDI Strategies, Issue 16, August 2, 2012

    On August 27, CMS launches its Recovery Audit Prepayment Review demonstration project. Over the...

Director’s Note: Quarterly Conference Call scheduled

  • CDI Strategies, Issue 16, August 2, 2012

    The next ACDIS Quarterly Conference Call is scheduled for this Thursday, August 16, from 1-2 p.m...

Membership Update: Local meetings offer CDI education through September

  • CDI Strategies, Issue 16, August 2, 2012

    ACDIS local chapters have several meetings scheduled in the coming months. As a reminder if you are...

News: CMS releases ICD-10 preparation tips and 2013 ICD-10-CM/PCS codes and mapping files

  • CDI Strategies, Issue 16, August 2, 2012

    CMS is expected to soon release its final timeline for ICD-10-CM/PCS implementation. Although it...

News: CMS redesigns Hospital Compare website

  • CDI Strategies, Issue 16, August 2, 2012

    CMS recently redesigned its Hospital Compare website to enhance navigation capabilities for users...

News: OIG finds PacifiCare received more than $100 million in overpayments

  • CDI Strategies, Issue 16, August 2, 2012

    A recent Office of the Inspector General report found PacifiCare of Texas received $115 million in...

News: Planned surgical readmission documentation may reduce expected readmission outcomes

  • CDI Strategies, Issue 16, August 2, 2012

    Unplanned readmissions may by overestimated by as much as 25%, according to a study by physicians...

2nd Annual CDI Week theme set, preparations underway

  • HIM-HIPAA Insider, Issue 3, July 23, 2012

    After hosting the first Clinical Documentation Improvement Week last year, the Association for...

Q&A: Documentation and coding for post-operative complications related to COPD

  • CDI Strategies, Issue 15, July 19, 2012

    Q: We recently had a case where a patient with severe chronic obstructive pulmonary disease...

Director’s Note: ACDIS seeks volunteers for the 2013 National Conference Committee

  • CDI Strategies, Issue 15, July 19, 2012

    The 2013 ACDIS Annual Conference Committee will help plan and shape next year's conference in...

New malnutrition criteria could help ensure consistent coding

  • JustCoding News: Inpatient, Issue 29, July 18, 2012

    New clinical guidelines for malnutrition could help alleviate compliance challenges associated with...

Q&A: Assigning a principal diagnosis for a patient with pneumonia and atrial fibrillation

  • JustCoding News: Inpatient, Issue 29, July 18, 2012

    QUESTION: A patient is admitted with pneumonia and atrial fibrillation and both are present on...

Q&A: Query forms for acute and chronic respiratory failure

  • HIM-HIPAA Insider, Issue 2, July 16, 2012

    Q: Our pulmonologists are not comfortable documenting acute respiratory failure unless a patient is...

Coding for an atypical small acinar proliferation of the prostate

  • HIM-HIPAA Insider, Issue 1, July 9, 2012

    Q: Which code should I report for atypical small acinar proliferation of the prostate? Is ICD-9-CM...

Q&A: Determine medical necessity for inpatient admissions for COPD

  • CDI Strategies, Issue 14, July 5, 2012

    Q: Our hospital serves a higher than usual population with COPD. Most of these cases are chronic...

Membership Update: July, August networking events heat up

  • CDI Strategies, Issue 14, July 5, 2012

    ACDIS currently has more than 40 local chapters in most states. The following groups are holding...

Tip: Start with emergency room documentation to help reduce claims denials

  • CDI Strategies, Issue 14, July 5, 2012

    By Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI, CCDS Broaden the scope of your CDI...

Tip: Coding for inpatient postoperative complications requires explicit documentation

  • CDI Strategies, Issue 14, July 5, 2012

    Determining when to code a post-surgical complication as opposed to simply considering it to be an...

Director’s Note: Get ready for the second annual Clinical Documentation Improvement Week

  • CDI Strategies, Issue 14, July 5, 2012

    After hosting the first Clinical Documentation Improvement Week last year, ACDIS and the CDI...

Q&A: POA renal failure?

  • HIM-HIPAA Insider, Issue 27, July 3, 2012

    Q: A patient is admitted January 3 and undergoes spinal surgery that day. No laboratory specimens...

Director's Note: Comments regarding FY 2013 proposed IPPS rule due June 25

  • CDI Strategies, Issue 13, June 21, 2012

    On June 11, the ACDIS Advisory Board submitted comments to CMS regarding proposed changes to the...

Membership update: Review approved CEU activities for CCDS renewal

  • CDI Strategies, Issue 13, June 21, 2012

    The list of approved activities for continuing education units (CEU) applicable for the...

News: Nearly half of RAC appeals overturned in favor of providers

  • CDI Strategies, Issue 13, June 21, 2012

    CMS recently posted two separate sets of data that provide nationwide statistics on its Recovery...

Tip: Work with medical staff to mandate CDI orientation for new physicians

  • CDI Strategies, Issue 13, June 21, 2012

    Does your facility mandate physician participation in CDI orientation? That’s the question...

Tip: Seven steps to sort out SIRS documentation

  • CDI Strategies, Issue 13, June 21, 2012

    Current SIRS criteria are insufficient, confusing, and don't indicate whether a patient is truly...

Coding for clinical accuracy requires keen eye for detail

  • JustCoding News: Inpatient, Issue 25, June 20, 2012

    Why do coders need to know about Value Based Purchasing, the Readmissions Reduction Program...

Q&A: Coding for a chest x-ray showing atelectasis

  • HIM-HIPAA Insider, Issue 24, June 12, 2012

    Q: Our question pertains to the following scenario: The studies section of a history and physical...

Director's Note: Volunteers sought for drafting guidance on physician queries

  • CDI Strategies, Issue 12, June 7, 2012

    ACDIS invites you to join a work group to research industry needs and develop best practices for...

Membership Update: Policies, pocket guides, presentations added to ACDIS Library

  • CDI Strategies, Issue 12, June 7, 2012

    ACDIS members have access to the Forms & Tools Library which includes: Query forms...

News: OIG says physicians increased levels of E/M billing

  • CDI Strategies, Issue 12, June 7, 2012

    Over a nine-year period, from 2001 to 2010, physicians increased billing of higher level evaluation...

News: Study says dictated documentation less effective

  • CDI Strategies, Issue 12, June 7, 2012

    Patients of physicians using dictated electronic health records appear to be receiving lower...

News: Latest PEPPER released

  • CDI Strategies, Issue 12, June 7, 2012

    The latest Program for Evaluating Payment Patterns Electronic Report (PEPPER) was released May 24...

News: US Senator favors ICD-10 delay; AHIMA outlines its arguments against postponement

  • CDI Strategies, Issue 12, June 7, 2012

    US Senator Tom Coburn, MD, (R-OK) suggests Congress hold committee hearings regarding ICD-10...

News: OIG semi-annual report to Congress cites CMS limitations

  • CDI Strategies, Issue 12, June 7, 2012

    The Office of the Inspector General (OIG) pointed to deficiencies in CMS’ oversight of Zone...

Q&A: Clinical conversations vs. leading queries

  • CDI Strategies, Issue 11, May 24, 2012

    Q: Are clinical staff held to the same standard as coders and CDI staff regarding leading questions...

Tip: Add a little 'MUSIC' to documentation reviews

  • CDI Strategies, Issue 11, May 24, 2012

    By Donald A. Butler, RN New “variations” on reasons to query physicians was one topic...

Membership update: Quarterly Conference Call Thursday

  • CDI Strategies, Issue 11, May 24, 2012

    The next ACDIS Quarterly Conference Call is scheduled for this Thursday, May 24, from 1-2 p.m., ET...

News: Identify potential Medicaid RAC target areas

  • CDI Strategies, Issue 11, May 24, 2012

    The Medicaid RAC program kicked off January 1. Although the program got off to a slow start...

News: Code freeze to extend through ICD-10 implementation

  • CDI Strategies, Issue 11, May 24, 2012

    After HHS proposed a year-long delay of ICD-10-CM/PCS, questions emerged regarding the current...

Tip: AHA Audit Education Series offers CDI program targets, support

  • CDI Strategies, Issue 11, May 24, 2012

    The May 14 American Hospital Association (AHA) edition of its Audit Education Series: Reducing...

Seven savvy tips for coding sepsis and SIRS

  • JustCoding News: Inpatient, Issue 21, May 23, 2012

    Many physicians say that systemic inflammatory response syndrome (SIRS) criteria are insufficient...

Q&A: Acute respiratory failure diagnosis does not require intubation

  • HIM-HIPAA Insider, Issue 21, May 22, 2012

    Q: Our pulmonologists are not comfortable documenting acute respiratory failure unless the patient...

News: NHIC Inc., finds one-day inpatient stays have high denial rates

  • CDI Strategies, Issue 10, May 10, 2012

    “This claim was denied after review and it was determined that the documentation did not...

White Paper: Mastering the three-day payment rule

  • CDI Strategies, Issue 10, May 10, 2012

    CMS’ three-day rule defines certain preadmission services as inpatient operating costs...

Director's Note: 5th Annual ACDIS Conference underway

  • CDI Strategies, Issue 10, May 10, 2012

    Today marks the official start of the 2012 5th Annual ACDIS Conference. We are so happy to see so...

Membership Update: Quarterly Conference Call scheduled for May 24

  • CDI Strategies, Issue 10, May 10, 2012

    The next Quarterly Conference Call is scheduled for Thursday, May 24, 1-2 p.m., ET. ACDIS members...

News: Celebrate National Nurses Week!

  • CDI Strategies, Issue 10, May 10, 2012

    The American Nurses Association (ANA) and nurses across the country are celebrating National Nurses...

News: CMS releases latest compliance newsletter

  • CDI Strategies, Issue 10, May 10, 2012

    The April edition of CMS’ Medicare Quarterly Provider Compliance Newsletterincludes...

The ICD-10 implementation delay and its effect on coders

  • JustCoding News: Inpatient, Issue 19, May 9, 2012

    HHS has announced a proposed rule that would postpone ICD-10-CM/PCS implementation from October 1...

News: CMS adds spending per beneficiary to Hospital Compare data

  • CDI Strategies, Issue 9, April 26, 2012

    CMS’ Hospital Compare website now also illustrates how much facilities spend per Medicare...

Q&A: Anesthesia records and querying for blood transfusion

  • CDI Strategies, Issue 9, April 26, 2012

    Q: A patient has low rectal cancer. The surgeon performed a robotic lap colon resection. The tissue...

News: IPPS proposed rule expands VBP, increases IPPS payment

  • CDI Strategies, Issue 9, April 26, 2012

    CMS projects that payment rates to general acute care hospitals will increase by 2.3% in fiscal...

Director's Note: ACDIS advises members to 'stay the course' despite potential ICD-10 delay

  • CDI Strategies, Issue 9, April 26, 2012

    As I’m sure most of you are aware, The Department of Health and Human Services (HHS) has...

Conference Updates: The 5th Annual ACDIS Conference won't be all work

  • CDI Strategies, Issue 9, April 26, 2012

    We have some of the fun events planned for San Diego! If you have any questions, don’t...

Membership Update: Volunteers sought to review Forms & Tools Library/ACDIS website

  • CDI Strategies, Issue 9, April 26, 2012

    In the coming year ACDIS plans to complete a revision of its website. Please help us meet your...

News: CDI Journal released, study shows CDI programs plan to increase ICD-10 training

  • CDI Strategies, Issue 8, April 12, 2012

    The HHS proposed delay in ICD-10 implementation may be welcome news for many facilities since...

News: Hospital settles allegations of False Claims Act violations related to malnutrition and leading queries

  • CDI Strategies, Issue 8, April 12, 2012

    A Maryland hospital allegedly added malnutrition as a secondary diagnosis, employing tactics that...

Membership Update: Quarterly conference calls dates announced

  • CDI Strategies, Issue 3, April 12, 2012

    The next two ACDIS Quarterly Conference Calls will be held on Thursday, May 24, from 1-2 p.m., and...

Conference update: Hotel deadline for reduced rate Monday, April 16

  • CDI Strategies, Issue 8, April 12, 2012

    The cutoff date for the reduced $199 per night rate at the Manchester Grand Hyatt is Friday, April...

Q&A: Clarifying ’septic shock’

  • CDI Strategies, Issue 8, April 12, 2012

    Q:  If a physician documents “septic shock” should the CDI specialist query for...

News: One-year delay proposed for ICD-10 implementation, industry comments sought

  • CDI Strategies, Issue 8, April 12, 2012

    HHS released a proposed rule Monday, April 9, regarding a potential one-year delay of the...

Director’s Note: ACDIS welcomes new CDI Education Director

  • CDI Strategies, Issue 8, April 12, 2012

    ACDIS is proud to welcome its new CDI Education Director, Cheryl Ericson, MS, RN. In this role...

News: Decline in pneumonia mortality may be due to shift in documentation and coding

  • CDI Strategies, Issue 8, April 12, 2012

    Just because hospitalizations and inpatient admissions due to pneumonia declined from 2003 to 2009...

Director’s Note: Get HIP, celebrate Health Information Professionals Week

  • CDI Strategies, Issue 7, March 29, 2012

    This week marks the 23rd annual AHIMA sponsored Health Information Professionals Week (HIP), themed...

Membership Update: Sample queries added to the Forms & Tools Library; volunteers sought

  • CDI Strategies, Issue 7, March 29, 2012

    ACDIS members have access to a collection of sample Forms & Tools donated by their peers...

2012 Conference Update: Reminder about deadlines for hotel reservations and CCDS exam

  • CDI Strategies, Issue 7, March 29, 2012

    As of this week, more than 600 CDI-related professionals had registered for the 2012 ACDIS...

News: CMS targets April for release of new ICD-10-CM/PCS implementation date

  • CDI Strategies, Issue 7, March 29, 2012

    During a March 7 conference call with payers, CMS indicated that it expects to release information...

News: CMS delays HIPAA Version 5010 enforcement date

  • CDI Strategies, Issue 7, March 29, 2012

    CMS delayed the HIPAA Version 5010 compliance deadline again last week, giving providers until June...

News: ICD-9-CM Coordination and Maintenance Committee discusses few code changes

  • CDI Strategies, Issue 7, March 29, 2012

    The ICD-9-CM Coordination and Maintenance (C&M) Committee discussed a few changes to the...

News: OIG says CMS overestimates payment error rates

  • CDI Strategies, Issue 7, March 29, 2012

    The Office of the Inspector General (OIG) says CMS incorrectly estimates payment errors in its...

News: Latest version of the ICD-10 MS-DRG conversion project available.

  • CDI Strategies, Issue 7, March 29, 2012

    CMS posted v29 of the ICD-10 MS-DRGs and an updated version of the v27 Medicare Code Editor (MCE...

Q&A: Educate physicians regarding TIA etiologies

  • CDI Strategies, Issue 7, March 29, 2012

    Q: Can you please help me locate information regarding etiologies of transient ischemic attack...

Don’t jump to conclusions about documentation

  • JustCoding News: Inpatient, Issue 13, March 28, 2012

    These days, documentation improvement and compliance are at the forefront of coders' minds. In some...

Be diligent about documentation review to prevent denials and ensure sufficient detail supports medical necessity

  • JustCoding News: Inpatient, Issue 13, March 28, 2012

    How does medical necessity get “overlooked” on the physician side as well as the...

Q&A: Coding for pneumonia with malnutrition secondary to feeding difficulties of the elderly

  • HIM-HIPAA Insider, Issue 12, March 20, 2012

    Q: A physician admitted a patient with pneumonia, which was the first diagnosis. The second...

News: Government recovers $4 billion via healthcare fraud prevention/enforcement

  • CDI Strategies, Issue 6, March 15, 2012

    The Department of Health and Human Services (HHS) recovered nearly $4.1 billion in taxpayer dollars...

News: J12 MAC company merges, becomes ’Novitas Solutions, Inc.’

  • CDI Strategies, Issue 6, March 15, 2012

    The Medicare Administrative Contractor (MAC) for J12, which covers Delaware, New Jersey...

Tip: Take advantage of nutrition month for your physician training

  • CDI Strategies, Issue 6, March 15, 2012

    March is “National Nutrition Month,” according to a recent release from CMS. CDI...

Q&A: Code or query for clinical significance?

  • CDI Strategies, Issue 6, March 15, 2012

    Q: We are having a discussion about how to code when the history and physical (H&P), under...

Tip: New materials posted to the Forms & Tools Library

  • CDI Strategies, Issue 6, March 15, 2012

    The following materials have been posted to the Forms & Tools Library on the ACDIS website...

Director’s note: Roadmap Committee charts path for new CDI programs

  • CDI Strategies, Issue 6, March 15, 2012

    ACDIS formed the CDI Roadmap Committee in September 2011 to help define some of the core...

2012 Conference Update: LaRosa to teach CDI-ICD-10 Boot Camp; additional rooms made available

  • CDI Strategies, Issue 6, March 15, 2012

    ACDIS welcomes Adelaide M. La Rosa, RN, BSN, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer and...

Membership Update: New local groups looking for volunteers, participants

  • CDI Strategies, Issue 6, March 15, 2012

    ACDIS thanks the volunteers who have stepped forward to gather CDI professionals in their regions...

News: CMS releases proposed rules for Stage 2 EHR meaningful use requirements

  • CDI Strategies, Issue 6, March 15, 2012

    HHS proposed electronic health record (EHR) systems’ Stage 2 meaningful use requirements in a...

News: Quality Forum leader to step down

  • CDI Strategies, Issue 6, March 15, 2012

    After serving as the president of the National Quality Forum (NQF) for more than six years, Janet...

Tip: Say so long to eponyms in ICD-10-PCS

  • CDI Strategies, Issue 5, March 1, 2012

    What’s in a name? That which we call a rose by any other name would smell as sweet. At least...

Director’s Note: Annual conference early registration deadline March 9

  • CDI Strategies, Issue 5, March 1, 2012

    The 5th Annual ACDIS Conference early registration cutoff date is next Friday, March 9. This year's...

Membership Update: Quarterly Conference Call recording posted

  • CDI Strategies, Issue 5, March 1, 2012

    The February 16 ACDIS Quarterly Conference Call is now available for download on the ACDIS website...

News: Sample VBP reports available on QualityNet

  • CDI Strategies, Issue 5, March 1, 2012

    As of Wednesday, February 29, hospitals can access their Value-Based Purchasing Simulated Hospital...

News: PEPPER ready for review

  • CDI Strategies, Issue 5, March 1, 2012

    The fourth quarter 2011 Short-Term Acute Care Program for Evaluating Payment Patterns Electronic...

News: Revenue Cycle Institute posts '2011 Recovery Auditor Benchmarking Report'

  • CDI Strategies, Issue 5, March 1, 2012

    More than 400 individuals responded to the “2011 Recovery Auditor Benchmarking Survey&rdquo...

News: Review Medicaid Integrity Contractors identify $282 million in potential overpayments

  • CDI Strategies, Issue 5, March 1, 2012

    Review Medicaid Integrity Contractors (MICs) completed 81% of their CMS assignments resulting in...

Scrutinize documentation in 2012 and beyond

  • JustCoding News: Inpatient, Issue 9, February 29, 2012

    Even if you didn’t make a personal New Year's resolution, you should make a professional one...

Outpatient CDI efforts offer documentation opportunities

  • JustCoding News: Outpatient, Issue 8, February 22, 2012

    Payers are now looking to ensure that physician and facility billing match, which could mean new...

News: Trailblazer blames lack of documentation for MS-DRG 246 denials

  • CDI Strategies, Issue 4, February 16, 2012

    Fifty-eight percent of claims billed with MS-DRG 246, percutaneous cardiovascular procedure with...

Q&A: Review palliative care charts and query for 'comfort care' when appropriate

  • CDI Strategies, Issue 4, February 16, 2012

    Q: I had a followup question about the Jan. 5, 2012 CDI Strategies article (“Important change...

Membership Update: Facebook sites consolidated

  • CDI Strategies, Issue 4, February 16, 2012

    ACDIS recently closed its Facebook “Group” and invited participants in that forum to...

News: CMS releases first quarter report regarding Recovery Audit Program

  • CDI Strategies, Issue 4, February 16, 2012

    CMS’ Recovery Auditors (previously called Recovery Audit Contractors, now associated with the...

News: Nations largest insurers change physician payments

  • CDI Strategies, Issue 4, February 16, 2012

    UnitedHealthcare became the latest private insurer to announce plans to tie its reimbursement to...

News: CMS adds central line-associated bloodstream infections (CLABSIs) to Hospital Compare data reports

  • CDI Strategies, Issue 4, February 16, 2012

    Central line-associated bloodstream infections (CLABSIs) result in an estimated $700 million in...

News: CMS hints at possible delay in ICD-10 implementation deadline

  • CDI Strategies, Issue 4, February 16, 2012

    CMS acting administrator Marilyn Tavenner indicated that the agency could be considering a revision...

Director’s Note: Quarterly Conference Call agenda includes query discussion, guidance from CMS contractors

  • CDI Strategies, Issue 4, February 16, 2012

    The ACDIS quarterly conference call is scheduled for today, Thursday, February 16, from 1-2 p.m...

Director’s Note: ACDIS members elect four new ACDIS Advisory Board members

  • CDI Strategies, Issue 3, February 2, 2012

    ACDIS would like to welcome four new members to the advisory board. These new board members are the...

Membership Update: New content added to ACDIS site; reminders for members

  • CDI Strategies, Issue 3, February 2, 2012

    Professional of the year nominee deadline Click here to download the 2012 award nomination form...

News: Poll, survey indicates CDI salary range

  • CDI Strategies, Issue 3, February 2, 2012

    Of 165 respondents who took part in a recent website poll, 50 (30%) indicated they earn more than...

News: Vendor survey indicates physician documentation top priority for ICD-10 preparation

  • CDI Strategies, Issue 3, February 2, 2012

    More than 65% of respondents listed improving physician documentation as “the most important...

News: Study finds physicians need more help with electronic records

  • CDI Strategies, Issue 3, February 2, 2012

    Transitioning to electronic health records (EHR) is no longer a question of “if” but...

News: Nurses spending more time on indirect patient care

  • CDI Strategies, Issue 3, February 2, 2012

    Three hours a day. That’s how much time, out of a 12-hour shift, nurses say they spend on...

Q&A: Coming to terms with the clinical/coding language disconnect

  • CDI Strategies, Issue 3, February 2, 2012

    Q:  I am fairly new to CDI and I have a nursing background. I’m trying to understand how...

News: Advisory Board voting to begin next week

  • CDI Strategies, Issue 2, January 19, 2012

    Look for special e-mail instructions in the coming week directing ACDIS members to an online voting...

Director’s Note: First Quarterly Conference call of 2012 scheduled; your questions wanted

  • CDI Strategies, Issue 2, January 19, 2012

    Mark your calendars: The first ACDIS quarterly conference call of 2012 has been scheduled for...

Membership Update: New Local Chapter page published

  • CDI Strategies, Issue 2, January 19, 2012

    ACDIS recently updated its website Local Chapter networking page. To connect with Local Chapter...

Conference Update: 2012 CDI Professional of the Year nominations, poster session submission period open; additional discount hotel rooms acquired

  • CDI Strategies, Issue 2, January 19, 2012

    Professional of the Year nominations It’s time to submit your nominations for the 2012 CDI...

News; CMS releases online list of DRGs for ICD-10

  • CDI Strategies, Issue 2, January 19, 2012

    CMS recently published a draft ICD-10 MS-DRG definitions. According to the website, the definitions...

Tip: MLN Matters article stresses importance of complete record review

  • CDI Strategies, Issue 2, January 19, 2012

    MLN Matters article SE1121 emphasizes that coders must consider all documentation from licensed...

Q&A: Proper sequencing of heart failure with hypertensive heart/kidney disease

  • CDI Strategies, Issue 2, January 19, 2012

    Q:I have a question regarding sequencing. I would usually have sequenced 428.21 (heart failure) as...

News: CMS debuts web page for ICD-10 CC and MCC lists

  • CDI Strategies, Issue 1, January 5, 2012

    CMS recently released ICD-10 CC and MCC lists on its web site. It lists the diagnosis by ICD-10...

News: Important change impacts all CDI programs that review mortality charts

  • CDI Strategies, Issue 1, January 5, 2012

    CDI specialists that incorporate quality measures review in their duties take note: The Joint...

Conference opportunity: Poster submissions open for 2012 ACDIS conference

  • CDI Strategies, Issue 1, January 5, 2012

    The 5th annual ACDIS conference, to be held May 10-11, 2012 at the Manchester Grand Hyatt in San...

Q&A: When is it appropriate to query for aspiration pneumonia?

  • CDI Strategies, Issue 1, January 5, 2012

    Q:A physician admitted a patient with pneumonia, which was the first diagnosis. The second...

Pre-conference event: Physician advisor session expanded

  • CDI Strategies, Issue 1, January 5, 2012

    If you are a physician advisor, or a CDI department manager looking to add or get the most out of a...

Director’s Note: CDI Journal offers insight for expanding CDI roles

  • CDI Strategies, Issue 1, January 5, 2012

    The January 2012 CDI Journal has been posted on the ACDIS web site. This edition includes two...

Membership update: New materials posted to the Forms & Tools Library

  • CDI Strategies, Issue 1, January 5, 2012

    There have been a number of additions to the Forms & Tools Library thanks to the donations and...

Tip: Consider the benefits of inter-departmental coding conferences with ICD-10 on the horizon

  • CDI Strategies, Issue 27, December 22, 2011

    Most of the cases that HIM professionals code are straightforward; some are more difficult, and a...

Director’s Note: Clarification regarding Coding Clinic publication

  • CDI Strategies, Issue 27, December 22, 2011

    The American Hospital Association (AHA) has not made any formal decisions regarding when it will...

Membership Update: Poster presentation submission period open

  • CDI Strategies, Issue 27, December 22, 2011

    The 5th annual ACDIS conference, to be held May 10-11, 2012 at the Manchester Grand Hyatt in San...

News: Trailblazer to begin prepayment reviews for four cardiac-related procedures

  • CDI Strategies, Issue 27, December 22, 2011

    Effective December 15, Trailblazer Health Enterprises, LLC, began prepay service-specific medical...

News: CMS to make more performance measurement data available to the public

  • CDI Strategies, Issue 27, December 22, 2011

    On December 7, CMS published a final rule in the Federal Register that will give qualified...

Q&A: ’Suggestive’ documentation could require clarification

  • CDI Strategies, Issue 27, December 22, 2011

    Q:Does documentation such as “suggestive of” or “suspicious of” qualify as...

News: Carefully examine syncope and collapse denials

  • CDI Strategies, Issue 26, December 8, 2011

    Hospitals reported syncope and collapse (MS-DRG 312) as the top MS-DRG with respect to financial...

Director’s Note: Certification handbook updates, reminder regarding recertification

  • CDI Strategies, Issue 26, December 8, 2011

    Are you planning to take the CCDS exam? If so, please note that we have made some revisions to the...

News: Ability to pay drives hospital length of stay

  • CDI Strategies, Issue 26, December 8, 2011

    Uninsured patients spend less time in the hospital than insured patients, while Medicare patients...

Tip: Note disconnect between late effect terminologies in guidelines vs. indices

  • CDI Strategies, Issue 26, December 8, 2011

    By Jennifer Avery, CCS, CPC, CPC-H, CPC-I Late effects are considered to be the residual effects...

Membership Update: Local Chapters announce December/January meetings

  • CDI Strategies, Issue 26, December 8, 2011

    Minnesota The next meeting of the Minnesota group will be a 3M sponsored event Friday, Dec. 16, 8...

Coding Clinics highlight documentation’s critical role in accurate stroke coding

  • JustCoding News: Inpatient, Issue 49, December 7, 2011

    Clinical documentation plays a vital role in all coding. It is especially important, however, when...

Pneumonia with a negative chest x-ray: Clinical diagnoses, physician documentation, and coding guidelines

  • JustCoding News: Inpatient, Issue 49, December 7, 2011

    As the weather cools, the heat is on coders to properly report the high number of pneumonia cases...

Coders play pivotal role in facilities’ efforts to curb improper payment allegations from auditors

  • JustCoding News: Inpatient, Issue 49, December 7, 2011

    Coders should not underestimate the vital role they play in their organization’s efforts to...

Q&A: Coding for arthroscopic patellofemoral resurfacing

  • HIM-HIPAA Insider, Issue 49, December 6, 2011

    Q: How should we code arthroscopic patellofemoral resurfacing? Some physicians want to code this as...

Tip: Evaluate CAC and software expenses

  • CDI Strategies, Issue 25, December 1, 2011

    Invest in computer-assisted coding (CAC) now because of its potential positive impact on...

Q&A: Making present-on-admission queries part of the record

  • CDI Strategies, Issue 25, December 1, 2011

    Q:Should present-on-admission (POA) queries stay in the record and become a part of the permanent...

Membership Update: ACDIS Blog opportunities

  • CDI Strategies, Issue 25, December 1, 2011

    The ACDIS Blog offers CDI specialists yet another forum to learn about CDI-related news and...

News: Demonstration program to expand RAC power

  • CDI Strategies, Issue 25, December 1, 2011

    Starting in January 2012, facilities could see pre-payment reviews from auditors involved in a new...

Membership Update: Next quarterly conference call Nov. 17

  • CDI Strategies, Issue 24, November 10, 2011

    A final reminder to our ACDIS membership that our next quarterly conference will take place next...

News: OIG Work Plan targets inpatient, outpatient mix for 2012

  • CDI Strategies, Issue 24, November 10, 2011

    The auditing arm of the Department of Health and Human Services (HHS) plans to crack down on...

News: CMS to hold ICD-10 implementation provider call

  • CDI Strategies, Issue 24, November 10, 2011

    CMS will host a National Provider Call on Thursday, November 17, 1:30-3 p.m. (ET) regarding ICD-10...

News: Value-based payment modifier details released

  • CDI Strategies, Issue 24, November 10, 2011

    On November 1, CMS issued its Medicare Physician Fee Schedule (MPFS) for calendar year 2012. In it...

News: CMS releases final rule governing ACOs

  • CDI Strategies, Issue 24, November 10, 2011

    On October 20, CMS released its long-awaited final rule governing accountable care organizations...

Tip: Monitor diagnoses targeted for readmission reduction

  • CDI Strategies, Issue 24, November 10, 2011

    Coders and CDI specialists need to understand the implications coding and sequencing may have on...

Q&A: Post-surgical complication of encephalopathy

  • CDI Strategies, Issue 24, November 10, 2011

    Q:Can a patient have encephalopathy after a surgery? For example, a patient post surgery...

Director’s Note: 2012 ACDIS annual conference speaking lineup finalized

  • CDI Strategies, Issue 24, November 10, 2011

    Thanks to the hard work of a volunteer conference committee, the 2012 ACDIS annual conference...

Membership Update: ACDIS Advisory Board applications due Nov. 25

  • CDI Strategies, Issue 24, November 10, 2011

    The nomination period for the ACDIS Advisory Board is open through November 25, 2011. ACDIS is...

Q&A: Coding for surgical debridement of devitalized tissue with scalpel

  • HIM-HIPAA Insider, Issue 45, November 8, 2011

    Q: One of our podiatrists documents “surgical debridement of devitalized tissue with...

Tip: Develop physician training to provide a crash course in documentation basics

  • CDI Strategies, Issue 23, October 27, 2011

    Since Emory Healthcare Inc., is a teaching hospital, Bonnie I. Epps, MN, RN, manager of its CDI...

Q&A: Resection or excision in ICD-10

  • CDI Strategies, Issue 23, October 27, 2011

    Q: I am unsure how “ribs” are categorized in ICD-10. I don’t understand if taking...

Director's Note: ACDIS Advisory Board nomination period open

  • CDI Strategies, Issue 23, October 27, 2011

    We are currently seeking four new ACDIS members to join our advisory board in 2012. ACDIS advisors...

Membership update: Quarterly conference call for ACDIS members scheduled

  • CDI Strategies, Issue 23, October 27, 2011

    The next ACDIS membership quarterly conference call is scheduled for Thursday, November 17, from...

News: HealthGrades report shows elevated risk of death at underperforming hospitals

  • CDI Strategies, Issue 23, October 27, 2011

    Patients cared for in facilities which HealthGrades deems as five-star have 73% less risk of dying...

News: CMS offers ICD-10 updates and training tools

  • CDI Strategies, Issue 23, October 27, 2011

    CMS recently updated its Medicare Severity (MS) Grouper with Medicare Code Editor (MCE) ICD-10 R1...

News: Maryland facility faces $8 million fraud charges for Kwashiorkor billing

  • CDI Strategies, Issue 23, October 27, 2011

    The Department of Health and Human Services and the Department of Defense accused Baltimore-based...

Coming soon in MRB

  • HIM-HIPAA Insider, Issue 42, October 18, 2011

    In the November issue of MRB, you’ll find articles on the following topics!

Director’s Note: ACDIS 2012 conference exhibitor prospectus offered

  • CDI Strategies, Issue 22, October 13, 2011

    We’re in the final stages of choosing speakers and sessions for the 5th Annual ACDIS National...

Membership Update: New tools, 4th Quarter CDI Journal posted

  • CDI Strategies, Issue 22, October 13, 2011

    The October edition of the CDI Journal has been posted. This issue includes: ACDIS Director...

News: Coding Clinic conversion unlikely, but some areas require clarification

  • CDI Strategies, Issue 22, October 13, 2011

    By Jennifer Avery, CCS, CPC, CPC-H, CPC-I As an AHIMA ICD-10 certified trainer, I have been doing...

News: CMS releases annual contractor satisfaction survey

  • CDI Strategies, Issue 22, October 13, 2011

    Based on overall satisfaction, CMS contractors received a mean score of 3.77 out of a maximum...

Director's Note: Visit ACDIS in Salt Lake City

  • CDI Strategies, Issue 20, September 29, 2011

    The 83rd AHIMA Convention and Exhibit takes place in a few days and ACDIS is proud to support the...

Membership Update: First annual CDI Week successes

  • CDI Strategies, Issue 20, September 29, 2011

    Thanks to all the CDI and related healthcare professionals who helped make the first annual CDI...

News: CMS releases Final Rule for Medicaid RACs

  • CDI Strategies, Issue 20, September 29, 2011

    On September 14, CMS released its Medicaid recovery audit contractor (RAC) final rule, which sets...

White Paper: Understand principal diagnosis selection factors to determine appropriate code assignment

  • CDI Strategies, Issue 20, September 29, 2011

    Documentation improvement staff often struggle with principal diagnosis selection. A clear...

Tip: What color is your PEPPER?

  • CDI Strategies, Issue 20, September 29, 2011

    The quarterly reports issued by the Program for Evaluating Payment Patterns Electronic Report...

Q&A: Coding Clinic clarifies SIRS query questions

  • CDI Strategies, Issue 20, September 29, 2011

    Q:  How should I query for systemic inflammatory response syndrome (SIRS) if SIRS codes...

Happy Clinical Documentation Improvement Week!

  • HIM-HIPAA Insider, Issue 38, September 20, 2011

    The first ever Clinical Documentation Improvement Week is being held this week, Sept. 18–24...

Director's Note: CDI Week celebrations commence!

  • CDI Strategies, Issue 18, September 15, 2011

    Well, we’re almost here at Clinical Documentation Improvement Week, which begins this Sunday...

Membership update: 2011 ACDIS Conference Special Section and slide show available

  • CDI Strategies, Issue 18, September 15, 2011

    ACDIS members can read about the highlights from this year’s conference, learn about the CDI...

News: Deadline for 2012 conference speaker applications closes Sept. 23

  • CDI Strategies, Issue 18, September 15, 2011

    The deadline to submit speaker applications for the 5th annual ACDIS conference (May 10-11, 2012...

CMS releases updated RAC Statement of Work

  • CDI Strategies, Issue 18, September 15, 2011

    CMS updated its Recovery Audit Contractor Statement of Work (SOW), according to an article in AHA...

News: HospitalCompare lists readmission 'worsts'

  • CDI Strategies, Issue 18, September 15, 2011

    Being described as "worse" in a CMS HospitalCompare data file is a dubious...

Tip: Take photographs of your CDI team to celebrate CDI Week

  • CDI Strategies, Issue 18, September 15, 2011

    If you’re looking for an easy, inexpensive way to celebrate the first annual Clinical...

Q&A: When to query physicians regarding pathological findings

  • CDI Strategies, Issue 18, September 15, 2011

    Q: Some of our physicians are uncomfortable making addendums to the discharge summary to include...

News: Lackluster RAC returns could spur fourth quarter records rush

  • CDI Strategies, Issue 18, September 2, 2011

    To make up a gap in expected overpayment collections Recovery Audit Contractors may escalate audit...

News: GAO report says CMS needs to improve quality of physician feedback

  • CDI Strategies, Issue 18, September 2, 2011

    “CMS faces challenges incorporating resource use and quality measures for physician feedback...

AHIMA to serve as secretariat on international health informatics committee

  • CDI Strategies, Issue 18, September 2, 2011

    AHIMA secured a “prestigious” role in the ongoing development of electronic healthcare...

Membership Update: CDI Week preparations include promotional products, surveys, and events

  • CDI Strategies, Issue 18, September 2, 2011

    In less than a month ACDIS kicks off the first ever Clinical Documentation Improvement Week...

News: CMS releases bundled payment information

  • CDI Strategies, Issue 18, September 2, 2011

    Trying to convince physicians that good documentation has “something in it for them” is...

News: Baptist Healthcare settles after claims of improper billing for sepsis, respiratory failure

  • CDI Strategies, Issue 18, September 2, 2011

    $8.9 million. That is the amount Kentucky-based Baptist Healthcare Systems, Inc., had to pay as of...

News: TrailBlazer probe highlights documentation disparity

  • CDI Strategies, Issue 18, September 2, 2011

    Out of 88 claims for MS-DRG 246 (percutaneous cardiovascular procedure with drug-eluting stent with...

Include physicians during transition to ICD-10: Three tips to help open the lines of communication

  • HIM-HIPAA Insider, Issue 35, August 30, 2011

    As coders sharpen their knowledge of anatomy and physiology and hone their ICD-10-CM/PCS skills...

Director’s Note: Quarterly call today, physician advisor survey closes tomorrow, September deadline for 2012 speaker proposals

  • CDI Strategies, Issue 17, August 18, 2011

    Conference call The next quarterly conference call for ACDIS members is scheduled for Thursday...

Membership Update: New renal failure coding e-learning course, Forms & Tools Library postings

  • CDI Strategies, Issue 17, August 18, 2011

    The ACDIS e-learning library allows members the ability to keep up to date on the latest issues and...

News: MACs to take over demand letter submission from RACs

  • CDI Strategies, Issue 17, August 18, 2011

    In January facilities should expect to receive Recovery Audit Contractors (RAC) demand letters not...

News: CMS adds mortality data for heart attack, heart failure, and pneumonia to Hospital Compare site

  • CDI Strategies, Issue 17, August 18, 2011

    CMS recently updated Hospital Compare web site data for 30-day mortality rates and 30-day...

News: Whistleblower case highlights leading query concerns

  • CDI Strategies, Issue 17, August 18, 2011

    It started with two courageous coders who knew the query process where they worked at Johns Hopkins...

Tip: Making sense of myocardial infarction sequencing rules

  • CDI Strategies, Issue 17, August 18, 2011

    By Linda Renee Brown, RN, CCRN, CCDS, MA One of the most confusing diagnoses to code and sequence...

Q&A: Keep query retention policies consistent

  • CDI Strategies, Issue 17, August 18, 2011

    Q: Should queries from different departments be treated and stored differently? Should they be...

Don’t remain silent if you observe a pattern of fraudulent conduct

  • HIM-HIPAA Insider, Issue 33, August 16, 2011

    It started with two courageous coders who knew the query process at Johns Hopkins Bayview Medical...

News: AHIMA releases ACO white paper

  • CDI Strategies, Issue 16, August 4, 2011

    Much discussion has been held of late regarding the creation of Accountable Care Organizations...

News: Palmetto issues warning about documentation error rates

  • CDI Strategies, Issue 16, August 4, 2011

    Healthcare providers in the A/B MAC jurisdiction 1 have a problem—a paid claims error rate...

Q&A: Definition of ’marrying’ DRGs

  • CDI Strategies, Issue 16, August 4, 2011

    Q: I am having trouble grasping the concept of “marrying” DRGs. Can you explain what...

Membership Update: Next Quarterly Conference Call slated for August 18

  • CDI Strategies, Issue 16, August 4, 2011

    The next quarterly conference call for ACDIS members is scheduled for Thursday, August 18, from 1-2...

Tip: CDI programs find expanded role in ED documentation efforts

  • CDI Strategies, Issue 16, August 4, 2011

    JA Thomas expanded its CDI offerings to include the ED and other points of entry roughly two years...

Director's Note: Join us on the podium at the 2012 ACDIS Conference

  • CDI Strategies, Issue 16, August 4, 2011

    We are currently seeking speakers to present at the 2012 ACDIS fifth Annual Conference, to be held...

News: IPPS Final Rule released

  • CDI Strategies, Issue 16, August 4, 2011

    CMS released the Inpatient Prospective Payment System (IPPS) Final Rule, Monday, Aug. 1, reducing a...

News: Latest CMS compliance newsletter could contain conflicting advice

  • CDI Strategies, Issue 16, August 4, 2011

    CMS recently released its July edition of the Medicare Quarterly Provider Compliance Newsletter but...

Q&A: Developing a query for malnutrition

  • CDI Strategies, Issue 15, July 21, 2011

    Q: Recently I have discussed the BMI and malnutrition status on patients with our Registered...

News: Congratulations to new CCDS credentialees

  • CDI Strategies, Issue 15, July 21, 2011

    The latest group of recipients of the CCDS credential met the requirements for the CCDS...

Director’s Note: Help kick-off Clinical Documentation Improvement Week

  • CDI Strategies, Issue 15, July 21, 2011

    ACDIS is sponsoring the industry’s first Clinical Documentation Improvement Week on Sept...

News: RACs target ventilator support

  • CDI Strategies, Issue 15, July 21, 2011

    RACs can easily data-mine for noncompliance related to coding for ventilator support, says Glenn...

Tip: Root operations terminology will make a difference in ICD-10 coding

  • CDI Strategies, Issue 15, July 21, 2011

    ICD-10-PCS codes include one digit for the root operation that the provider performs. The root...

Tip: Revenue Cycle Institute offers helpful tools at no cost

  • CDI Strategies, Issue 15, July 21, 2011

    Each month the Revenue Cycle Institute publishes a free sample tool or form for readers. This...

Membership update: Third quarter CDI Journal posted; new product of the month offered

  • CDI Strategies, Issue 14, July 7, 2011

    CDI Journal is a quarterly publication featuring in-depth articles regarding current...

News: Special MLN Matters article discusses RAC DRG vulnerabilities

  • CDI Strategies, Issue 14, July 7, 2011

    Inpatient hospital claims submitted to Medicare contain “a significant amount” of...

News: MAC contractor identifies E/M billing errors

  • CDI Strategies, Issue 14, July 7, 2011

    Evaluation and Management (E/M) services accounted for $28 billion in Part B payments nationally...

Tip: Query to clarify use of the term ’history’

  • CDI Strategies, Issue 14, July 7, 2011

    Many cases exist in which CDI specialists need to query physicians to clarify the use of the term...

Column: Defining 'failed' CDI programs

  • CDI Strategies, Issue 14, July 7, 2011

    I previously started a conversation on CDI Talk entitled “Failed Programs,” hoping...

Q&A: Determine documentation difference between skin graft and debridement

  • CDI Strategies, Issue 14, July 7, 2011

    Q:  I have been trying to determine whether a skin graft includes debridement. Based on what I...

Sibley Memorial Hospital, part of Johns Hopkins Medicine

  • CDI Strategies, Issue 0, June 24, 2011

    Date of Request: June 24, 2011 Job Title: SR. SPECIALIST, CLINICAL DOCUMENTATION IMPROVEMENT Name...

Membership update: CCDS CE credits available for Journal readers

  • CDI Strategies, Issue 13, June 23, 2011

    ACDIS is pleased to announce the availability of continuing education (CE) credits linked to its...

News: ACDIS, AHA comment to CMS on FY 2012 IPPS final rule

  • CDI Strategies, Issue 13, June 23, 2011

    ACDIS submitted comments to CMS regarding recent updates to the ICD-9-CM codes not included in the...

News: NQF releases update on reportable events list

  • CDI Strategies, Issue 13, June 23, 2011

    In 2002 the National Quality Forum (NQF) created its report Serious Reportable Events in...

News: JATA survey shows additional education needed to meet ICD-10 implementation needs

  • CDI Strategies, Issue 13, June 23, 2011

    J.A. Thomas and Associates (JATA) says nearly a quarter of healthcare facilities are not...

Tip: Oregon QIO posts physician query policy

  • CDI Strategies, Issue 13, June 23, 2011

    While the bulk of discussion regarding how to ethically and responsibly submit queries to...

Q&A: Standard rate of response from physicians

  • CDI Strategies, Issue 13, June 23, 2011

    Q:  Is there are industry standard for physician query response rate expectations? Our...

2012 IPPS proposed rule: What you need to know

  • HIM-HIPAA Insider, Issue 24, June 14, 2011

    CMS has released its fiscal year (FY) 2012 IPPS proposed rule, and coders need to note various...

Director's note: 2012 Conference Committee members sought

  • CDI Strategies, Issue 12, June 9, 2011

    Note: Due to a large volume of applications received, the application period is now closed. Our...

News: Proposed rule aims to increase opportunities for claims data scrutiny

  • CDI Strategies, Issue 12, June 9, 2011

    CMS released a new proposed rule on June 3 which aims to “give consumers and employers better...

News: ACDIS Quarterly Conference Call focuses on quality opportunities

  • CDI Strategies, Issue 12, June 9, 2011

    More than 300 ACDIS members dialed into the Quarterly Conference Call on Thursday, May 26 to learn...

News: CMS releases Medicaid HCACs final rule

  • CDI Strategies, Issue 12, June 9, 2011

    Provider-preventable conditions (PPC), including health care-acquired conditions (HCAC), are now...

News: Comment period on the IPPS proposed rule closes June 20

  • CDI Strategies, Issue 12, June 9, 2011

    CMS published the 2012 Inpatient Prospective Payment System (IPPS) proposed rule May 5 in the...

News: HHS plans review of existing rules

  • CDI Strategies, Issue 12, June 9, 2011

    On Thursday, May 26, the Department of Health and Human Services (HHS) announced its plans to...

Q&A: RAC, medical necessity, and the role of CDI

  • CDI Strategies, Issue 12, June 9, 2011

    Q: With all the auditing going on I would like to find out how effects CDI programs in other...

Note details when drafting physician queries

  • HIM-HIPAA Insider, Issue 23, June 7, 2011

    Coders should be mindful of the words they choose when drafting physician queries. Certain...

Membership updates: New job postings, forms and tools, blogs

  • CDI Strategies, Issue 11, May 26, 2011

    New job postings http://www.hcpro.com/acdis/jobs.cfm New forms and tools (see Physician...

News: Medicare money set to run out sooner than expected

  • CDI Strategies, Issue 11, May 26, 2011

    2024. Thirteen years. That’s how long Medicare’s trust fund is expected to last...

News: Hospital quality ratings sites fall short, study says

  • CDI Strategies, Issue 11, May 26, 2011

    “Publicly marketed hospital rating systems of surgical quality such as the US News &...

News: AHA releases first quarter 2011 RACTrac report

  • CDI Strategies, Issue 11, May 26, 2011

    Recovery Audit Contractors (RAC) reported doubled its recovery amounts since last...

Excerpt: Spread the word about physician legibility

  • CDI Strategies, Issue 11, May 26, 2011

    Legible. Complete. Dated, timed, signed, and authenticated. That's what section 482.24 of the...

Q&A: Pre-bill query process requires a defined policy and procedure

  • CDI Strategies, Issue 11, May 26, 2011

    Q:: What does ‘pre-bill retrospective physician query process’ mean?

Director’s Note: First group of CCDS credential holders due for recertification

  • CDI Strategies, Issue 10, May 12, 2011

    It seems to be hard to believe, but we’re approaching the two-year anniversary of the launch...

Membership update: White Paper regarding CDI role in RAC preparation posted

  • CDI Strategies, Issue 10, May 12, 2011

    What kind of return can your CDI program guarantee in terms of RAC preparedness? That’s the...

News: CMS posts value-based purchasing final rule

  • CDI Strategies, Issue 10, May 12, 2011

    A mandate of the Affordable Care Act, CMS’ value-based purchasing (VBP) program will begin in...

News: Poll suggest healthcare staffing shortage could affect quality improvement efforts

  • CDI Strategies, Issue 10, May 12, 2011

    Nearly 500 healthcare quality professionals indicated that staffing shortages could be the biggest...

News: CMS issues latest quarterly provider compliance newsletter

  • CDI Strategies, Issue 10, May 12, 2011

    Improper coding of MS-DRG 813 (coagulation disorders), reporting an extensive operating room...

News: CMS releases latest MS-DRG version, hosts ICD-10 teleconference

  • CDI Strategies, Issue 10, May 12, 2011

    Hospitals can start experimenting with how new ICD-10-CM/PCS codes will translate to MS-DRGs since...

Q&A: Including CC/MCC information on physician education materials

  • CDI Strategies, Issue 10, May 12, 2011

    Q:I’ve heard different opinions between the coders and some of our CDI consultants regarding...

Membership Update: ACDIS releases query practice and salary benchmark reports

  • CDI Strategies, Issue 9, April 28, 2011

    The 2010 CDI Specialist’s Salary Survey and the 2010 Physician Queries Benchmarking Report...

News: CMS proposed IPPS changes continue DCA reductions, include HAC and excisional debridement

  • CDI Strategies, Issue 9, April 28, 2011

    CMS expects a year-over-year reduction of 0.5% in payments to acute care hospitals under the...

News: AMA submits comments to CMS regarding federal regulatory burdens

  • CDI Strategies, Issue 9, April 28, 2011

    In response to President Barack Obama’s January 18 executive order aimed at reducing federal...

Tip: Use free resources to help you start your ICD-10 preparation efforts

  • CDI Strategies, Issue 9, April 28, 2011

    By Donald A. Butler, RN, BSN The more I learn about ICD-10, the more worried I get. At this...

Q&A: Productivity measures for CDI specialists

  • CDI Strategies, Issue 9, April 28, 2011

    Q: What is the recommended ratio for CDI professionals regarding the number of patients and...

ACDIS submits comments to CDC about proposed ICD-9-CM changes

  • HIM-HIPAA Insider, Issue 16, April 19, 2011

    The Association of Clinical Documentation Improvement Specialists (ACDIS) submitted comments March...

Director’s Note: Thanks for a successful conference

  • CDI Strategies, Issue 8, April 14, 2011

    Last week more than 700 CDI professionals attended the 4th Annual ACDIS Conference at the Hilton...

Membership update: CDI Journal available for download

  • CDI Strategies, Issue 8, April 14, 2011

    The April edition of the CDI Journal was posted last week, and is available to ACDIS members for...

News: CMS reports HAC rates, HAC program to come to Medicaid, renewed push for CDI specialist involvement

  • CDI Strategies, Issue 8, April 14, 2011

    Hospital acquired conditions (HAC): The phrase seems simple enough to understand. These are...

News: CDC releases 2011 ICD-10-CM/PCS coding guidelines, POA reporting

  • CDI Strategies, Issue 8, April 14, 2011

    The Centers for Disease Control (CDC) in March posted new 2011 guidelines for ICD-10-CM. There are...

Tip: Spread the word about physician legibility

  • CDI Strategies, Issue 8, April 14, 2011

    Legible. Complete. Dated, timed, signed, and authenticated. That's what section 482.24 of the...

Q&A: Pre-bill query process requires careful analysis

  • CDI Strategies, Issue 8, April 14, 2011

    Q: What does ‘pre-bill retrospective physician query process’ mean? A:A pre-bill...

Tips to help improve physician queries

  • HIM-HIPAA Insider, Issue 14, April 5, 2011

    Physician queries are a predictable part of any coder's job. Coders may pose hundreds—even...

Director's Note: ACDIS comments to CDC on proposed FY 2012 ICD-9-CM codes

  • CDI Strategies, Issue 7, March 31, 2011

    Members of the Association of Clinical Documentation Improvement Specialists (ACDIS) advisory board...

Membership update: ACDIS conference attendance tips

  • CDI Strategies, Issue 7, March 31, 2011

    We are very excited about the Fourth Annual ACDIS Conference next week (April 7-8, Orlando FL) and...

Column: Involve physicians in CDI program effort to enhance buy-in

  • CDI Strategies, Issue 7, March 31, 2011

    By Vickie Balistreri, BA, RHIA, CCS, CCS-P, CCDS, CPC, CPC-H “Tell me and I’ll...

Tip: Know when to report secondary diagnoses

  • CDI Strategies, Issue 6, March 17, 2011

    A patient’s medical record could include a laundry list of diagnoses, but not all of these...

Q&A: Avoid 'rule out' language to ensure medical necessity

  • CDI Strategies, Issue 6, March 17, 2011

    Q:I know that in an inpatient setting coders are allowed to use suspected diagnosis when a...

Maxim Moment: Success measurements in CDI

  • CDI Strategies, Issue 6, March 17, 2011

    by Steven Robinson, MS, PA-O, RN, CPUR What are the most important factors that measure success...

Director's Note: Hilton sold out, rooms available nearby

  • CDI Strategies, Issue 5, March 3, 2011

    Nearly 550 CDI professionals have registered to attend the 4th Annual ACDIS Conference in Orlando...

Membership update: CCDS recertification, new article of the month, virtual website tour

  • CDI Strategies, Issue 5, March 3, 2011

    A number of ACDIS members will be eligible for Certified Clinical Documentation Specialist...

News: Latest PEPPER reports released

  • CDI Strategies, Issue 5, March 3, 2011

    By Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI The Fourth Quarter PEPPER reports...

News: Medicare 'sting' charges more than 100 defendants including doctors and nurses

  • CDI Strategies, Issue 5, March 3, 2011

    The Department of Health and Human Services (HHS) called it the largest healthcare fraud sting in...

News: California facilities struggle with allegations of inappropriately billing for kwashiorkor

  • CDI Strategies, Issue 5, March 3, 2011

    If the data is true, the population of a couple of concentrated areas in California suffer from...

Q&A: Re-billing an account after a late query response

  • CDI Strategies, Issue 5, March 3, 2011

    Q: AHIMA’s 2008 practice brief, “Managing an Effective Query Process,” appears to...

Maxim Moment: Success measurements in CDI

  • CDI Strategies, Issue 5, March 3, 2011

    by Steven Robinson, MS, PA-O, RN, CPUR What are the most important factors that measure success...

Membership update: Review weekly polls, forms, job postings for useful information

  • CDI Strategies, Issue 4, February 17, 2011

    ACDIS conducts a new poll of its members nearly every week. Members can submit their responses and...

Maxim Moment: Success measurements in CDI

  • CDI Strategies, Issue 4, February 17, 2011

    by Steven Robinson, MS, PA-O, RN, CPUR What are the most important factors that measure success...

Q&A: Look for etiology when querying for renal failure

  • CDI Strategies, Issue 4, February 17, 2011

    Q: Since Acute Renal Failure (ARF) is no longer a MCC (as of October 1, 2010). I would like...

Tip: Documentation key to ensuring inpatient medical necessity

  • CDI Strategies, Issue 4, February 17, 2011

    The RACs have ramped up medical necessity reviews. Determining the medical necessity of an...

News: CMS offers variety of ICD-10 updates

  • CDI Strategies, Issue 4, February 17, 2011

    CMS released a number of helpful ICD-10 items recently including: The written transcript and...

News: RACs target respiratory system diagnosis with ventilator support

  • CDI Strategies, Issue 4, February 17, 2011

    A recent special edition MedLearn Matters article SE1028 outlines four risk areas targeted by the...

Director’s Note: Quarterly conference call for ACDIS members Feb. 24

  • CDI Strategies, Issue 4, February 17, 2011

    The next quarterly conference call for ACDIS members will be held on Thursday, February 24, 1-2...

Director's Note: Welcome new board members, conference early-bird rate ends tomorrow

  • CDI Strategies, Issue 3, February 3, 2011

    ACDIS is pleased to announce the election of four new advisory board members, terms of service...

Membership Update: New tools, e-learning course, February chapter meetings, and quarterly conference call

  • CDI Strategies, Issue 3, February 3, 2011

    A number of new tools and presentations have been posted to the ACDIS Forms & Tools Library...

News: CMS issues guidance on hospital inpatient admission decisions

  • CDI Strategies, Issue 3, February 3, 2011

    Despite the guidance CMS offers about proper inpatient admission decisions, hospitals still...

News: Open door forum on value-based purchasing program slated for next week

  • CDI Strategies, Issue 3, February 3, 2011

    As announced in the January 20 issue of CDI Strategies, CMS issued a proposed rule to establish a...

News: CMS says health spending slowed in 2009

  • CDI Strategies, Issue 3, February 3, 2011

    In a recent National Health Expenditure Accounts (NHEA) report, the group indicated that U.S...

Q&A: Reinforcing the importance of a physician advisor

  • CDI Strategies, Issue 3, February 3, 2011

    Q: Our small hospital has decided at this time that they no longer need the services of a Physician...

Maxim Moment: Success measurements in CDI

  • CDI Strategies, Issue 3, February 3, 2011

    by Steven Robinson, MS, PA-O, RN, CPUR What are the most important factors that measure success...

Briefings on Coding Compliance Strategies, February 2011

  • Briefings on Coding Compliance Strategies, Issue 2, February 1, 2011

    Learn about reporting secondary diagnoses,  assigning the POA indicator, ICD-10 procedure...

Membership update: January edition of the CDI Journal posted

  • CDI Strategies, Issue 2, January 20, 2011

    The January 2011 edition of the CDI Journal is available for ACDIS members on the association...

News: CMS releases improved Physician Compare tool

  • CDI Strategies, Issue 2, January 20, 2011

    At the start of the New Year, CMS released an enhanced Physician Compare site which “begins...

Maxim Moment: Success measurements in CDI

  • CDI Strategies, Issue 2, January 20, 2011

    by Steven Robinson, MS, PA-O, RN, CPUR What are the most important factors that measure success...

Director's Note: Highlights of the 4th annual 2011 ACDIS conference in Orlando

  • CDI Strategies, Issue 1, January 6, 2011

    Hurry; early bird discount expires on Feb. 4 Although we’re all getting back from the...

Membership reminder: CDI specialist annual salary survey open through January 7

  • CDI Strategies, Issue 1, January 6, 2011

    In 2008, a total of 132 individuals completed ACDIS’ CDI specialists’ salary survey. In...

News: ICD-10 crosswalks, White Paper, CMS teleconference available

  • CDI Strategies, Issue 1, January 6, 2011

    The transition from ICD-9-CM Volume 3 procedure codes to ICD-10-PCS will be by all accounts a...

Tip: Address inadequate HIPAA Security Rule-required policies and procedures

  • CDI Strategies, Issue 1, January 6, 2011

    CMS detailed seven shortcomings, including old and inadequate policies and procedures, in its 2009...

Tip: Form comprehensive query policies to govern both CDI and coding staff

  • CDI Strategies, Issue 1, January 6, 2011

    According to the 2010 Physician Query Benchmarking Report (to be released later this month) 54% of...

Q&A: Ready for Medicaid RAC?

  • CDI Strategies, Issue 1, January 6, 2011

    Q: How should providers prepare for Medicaid RACs?  

Sponsored Content: Incorporate quality mandates into the CDI function

  • CDI Strategies, Issue 1, January 6, 2011

    by Steven Robinson, MS, PA-O, RN, CPUR  The DRG system, implemented nationally in 1983, was...

The complicated process of reporting complications

  • HIM-HIPAA Insider, Issue 51, December 28, 2010

    As the Patient Protection and Affordable Care Act implementation progresses, the quality and...

Director's Note: Nominations sought for CDI Professional of the Year

  • CDI Strategies, Issue 26, December 23, 2010

    The nomination period for the 2011 CDI Professional of the Year award is open through January...

Membership update: CDI specialist annual salary survey open through January 7

  • CDI Strategies, Issue 26, December 23, 2010

    In 2008, a total of 132 individuals completed ACDIS’ CDI specialists’ salary survey. In...

News: CMS releases Fact Sheets regarding IPPS, POA, and HAC

  • CDI Strategies, Issue 26, December 23, 2010

    The Medicare Learning Network released three fact sheets of interest to CDI staff: The...

News: 2010 RAC Preparedness Benchmarking Report released

  • CDI Strategies, Issue 26, December 23, 2010

    The RAC program was fully under way in 2010, and providers continue to struggle with it as the year...

News: Hospital Compare update includes three new inpatient measures

  • CDI Strategies, Issue 26, December 23, 2010

    The Hospital Compare website, updated on Dec. 11, contains three new inpatient measures. These...

Tip: Thoughts for how to develop CDI metrics

  • CDI Strategies, Issue 26, December 23, 2010

    by Donald A. Butler, RN, CCDS One analysis I particularly like is a metric I refer to as chart...

Sponsored Content: Incorporate quality mandates into the CDI function

  • CDI Strategies, Issue 26, December 23, 2010

      by Steven Robinson, MS, PA-O, RN, CPUR  The DRG system, implemented nationally in...

News: NQF issues proposed new definition of items retained during surgery

  • CDI Strategies, Issue 25, December 9, 2010

    The National Quality Forum (NQF) published a draft report updating the NQF-endorsed Serious...

News: MedPAC chair unveils full ?market basket? update proposal for inpatient payments

  • CDI Strategies, Issue 25, December 9, 2010

    The Medicare Payment Advisory Commission (MedPAC) considered a draft recommendation from its chair...

News: DOJ recovers record $3 billion from fraud claims

  • CDI Strategies, Issue 25, December 9, 2010

    The Department of Justice (DOJ) recovered $2.5 billion in healthcare fraud recoveries for fiscal...

News: Comment period for ACOs closes

  • CDI Strategies, Issue 25, December 9, 2010

    CMS sought comments from healthcare providers regarding proposed implementation of accountable care...

News: AHIMA releases recertification guidelines for ICD-10

  • CDI Strategies, Issue 25, December 9, 2010

    The Commission on Certification for Health Informatics and Information Management (CCHIIM) recently...

Tool: 3rd/4th Quarter Coding Clinic CDI updates available for ACDIS members

  • CDI Strategies, Issue 25, December 9, 2010

    Editor’s note: ACDIS recently published Coding Clinic update, a review of the most recent...

Sponsored Content: Incorporate quality mandates into the CDI function

  • CDI Strategies, Issue 25, December 9, 2010

    by Steven Robinson, MS, PA-O, RN, CPUR  The DRG system, implemented nationally in 1983, was...

Briefings on Coding Compliance Strategies, December 2010

  • Briefings on Coding Compliance Strategies, Issue 12, December 1, 2010

    Learn about the OIG work plan, acute kidney injursy, acute kidney failure, documentation and DNFB...

News: CMS publishes 2011 RAC ADR limits for providers

  • CDI Strategies, Issue 24, November 24, 2010

    CMS has modified the additional documentation request (ADR) limits (i.e., medical record request...

News: Polls illustrate CDI programs seek RN staff

  • CDI Strategies, Issue 24, November 24, 2010

    A recent ACDIS poll asked “which type of professional comprises the majority of your CDI...

Membership update: 2010 physician query benchmarking survey launched

  • CDI Strategies, Issue 23, November 11, 2010

    ACDIS Work Group members spent considerable energy creating the 2010 Physician Query Benchmarking...

News: Proposed rule on Medicaid RACs sets April 2011 as start target

  • CDI Strategies, Issue 23, November 11, 2010

    CMS released the long-anticipated proposed rule for Medicaid recovery audit contractors (RACs...

News: Coding Clinic wins out over SE MLN Matters article advice

  • CDI Strategies, Issue 23, November 11, 2010

    On October 14, we reported that CMS issued a controversial MLN Matters special edition (SE) article...

AHIMA releases ethics guidance for CDI professionals

  • CDI Strategies, Issue 23, November 11, 2010

    In the spring, AHIMA released its “Guidance for Clinical Documentation Improvement...

Tool: Body Mass Index documentation reminder flyer

  • CDI Strategies, Issue 23, November 11, 2010

    CDI specialists need to use all the tools available in their documentation training box to...

Updates on the ACDIS website

  • CDI Strategies, Issue 23, November 11, 2010

    The following items have been updated on the ACDIS website:  2011 ICD-9-CM codes...

Sponsored Content: Incorporate quality mandates into the CDI function

  • CDI Strategies, Issue 23, November 11, 2010

    by Steven Robinson, MS, PA-O, RN, CPUR  The DRG system, implemented nationally in 1983, was...

Ready your CDI staff for ICD-10 implementation

  • HIM-HIPAA Insider, Issue 43, November 2, 2010

    Three years. That’s how long you have to prepare for the implementation of the International...

Briefings on Coding Compliance Strategies, November 2010

  • Briefings on Coding Compliance Strategies, Issue 11, November 1, 2010

    Learn about medical necessity audits, linking signs and symptoms with definitive conditions...

News: Partial freeze of code changes announced

  • CDI Strategies, Issue 22, October 28, 2010

    At the September 15, 2010 ICD-9-CM Coordination & Maintenance Committee Meeting, the committee...

News: Sepsis survivors face future health problems

  • CDI Strategies, Issue 22, October 28, 2010

    Patients who survive sepsis infections face a long battle with cognitive and physical decline...

Tip: Cirrhosis and alcoholic hepatitis

  • CDI Strategies, Issue 22, October 28, 2010

    MS-DRG 432 (cirrhosis and alcoholic hepatitis with MCC) is one of many MS-DRGs slated for RAC...

Column: MLN Matters article offers insight for CDI role

  • CDI Strategies, Issue 22, October 28, 2010

    by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS The release of CMS Medlearn Matters articles...

Q&A: Offering physicians options does not necessarily pose compliance risk

  • CDI Strategies, Issue 22, October 28, 2010

    Q: Recently, a consultant suggested that if we asked the physician to clarify systolic/diastolic on...

Sponsored Content: Incorporate quality mandates into the CDI function

  • CDI Strategies, Issue 22, October 28, 2010

    by Steven Robinson, MS, PA-O, RN, CPUR  The DRG system, implemented nationally in 1983, was...

Membership Update: CDI Journal features e-query tips, ICD-10 benchmarking survey

  • CDI Strategies, Issue 21, October 14, 2010

    The latest edition of the CDI Journal published October 1 and is now posted to the ACDIS website...

News: MLN Matters article SE1028 rewrites rules of reporting secondary diagnoses

  • CDI Strategies, Issue 21, October 14, 2010

    A recent MLN Matters article has changed the official coding guidelines to define what...

News: Kaiser donates medical terminology database to HHS

  • CDI Strategies, Issue 21, October 14, 2010

    Kaiser Permanente recently donated its electronic database of medical terminology to the National...

Tip: What to include in a homegrown analysis of CDI

  • CDI Strategies, Issue 21, October 14, 2010

    When it comes to tracking CDI program data, many facilities fall back on the information provided...

Column: What impact will ICD-10 have on MS-DRG payments?

  • CDI Strategies, Issue 21, October 14, 2010

    by Shannon McCall, RHIA, CCS, CCS-P, CPC-I, CCDS I often wondered how the ICD-9-CM code set would...

Sponsored Content: Incorporate quality mandates into the CDI function

  • CDI Strategies, Issue 21, October 14, 2010

    by Steven Robinson, MS, PA-O, RN, CPUR The DRG system, implemented nationally in 1983, was the...

Tip: Anatomy to know when capturing debridement documentation

  • CDI Strategies, Issue 20, September 30, 2010

    Just because physicians may document the term excisional debridement it doesn’t mean that...

News: Use OIG compliance tips for ICD-10 implementation

  • CDI Strategies, Issue 20, September 30, 2010

    Realizing that the go-live date won’t change, some facilities already have organization-wide...

Column: Offer insight in addition to education when training physicians

  • CDI Strategies, Issue 20, September 30, 2010

    By Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS I recently received a fortune cookie from a...

Q&A: Obtaining documentation for multiple significant trauma

  • CDI Strategies, Issue 20, September 30, 2010

    Q: Whenever we get a trauma patient, it’s either very easy to get to the multiple significant...

Sponsored content: The art of physician education

  • CDI Strategies, Issue 20, September 30, 2010

    by Steven Robinson, RN Most physicians want to provide an accurate written picture of their...

Revenue Cycle Institute offers free white papers

  • HIM-HIPAA Insider, Issue 38, September 28, 2010

    Did you know that HCPro Revenue Cycle Institute offers free white papers on a variety of coding and...

News: Inpatient admissions decision fuels RAC uncertainty

  • CDI Strategies, Issue 19, September 16, 2010

    Recent approval of a RAC issue for inpatient hospital claims review has initiated uncertainty...

Tip: Pay attention to query retention

  • CDI Strategies, Issue 19, September 16, 2010

    Retaining written, templated, and verbal queries in document form is necessary to ensure CDI...

Q&A: Michigan ACDIS chapter offers opinions on verbal orders in CDI

  • CDI Strategies, Issue 19, September 16, 2010

    Q: Our CDI specialists call the physicians when queries have not been answered. Sometimes the...

Sponsored content: The art of physician education

  • CDI Strategies, Issue 19, September 16, 2010

    by Steven Robinson, RN Most physicians want to provide an accurate written picture of their...

Director's Note: Last chance to participate in ICD-10 survey

  • CDI Strategies, Issue 18, September 2, 2010

    Nearly 300 people have already responded to the ICD-10 for Clinical Documentation Improvement...

News: Report cites lack of detailed physician documentation as challenge to effective electronic health record initiatives

  • CDI Strategies, Issue 18, September 2, 2010

    As facilities vie for government incentives to implement electronic health record systems they may...

News: Review coding, documentation guidelines for latest RAC target-neoplasms

  • CDI Strategies, Issue 18, September 2, 2010

    Confusing coding guidelines and insufficient documentation have made neoplasms a target area as...

Tip: Audit records for signature documentation

  • CDI Strategies, Issue 18, September 2, 2010

    CMS requires that orders for healthcare services be authenticated using either a handwritten or...

Q&A: Facility policies should dictate whether queries are part of the medical record

  • CDI Strategies, Issue 18, September 2, 2010

    Q: If a CDI specialist or coder queries a physician and the response is written on the query letter...

Sponsored content: The art of physician education

  • CDI Strategies, Issue 18, September 2, 2010

    by Steven Robinson, RN Most physicians want to provide an accurate written picture of their...

Briefings on Coding Compliance Strategies, September 2010

  • Briefings on Coding Compliance Strategies, Issue 9, September 1, 2010

    Learn about the FY 2011 IPPS final rule, the three-day payment rule, documentaiton and coding...

Director's Note: Speakers sought for ACDIS 2011 conference

  • CDI Strategies, Issue 17, August 19, 2010

    We are currently seeking speakers to present at the 2011 ACDIS Fourth Annual Conference, to be held...

News: CMS approves first of RAC medical necessity reviews

  • CDI Strategies, Issue 17, August 19, 2010

    The Centers for Medicare & Medicaid Services (CMS) recently approved the first “medical...

Tool: Alternative staff schedules offer CDI opportunities

  • CDI Strategies, Issue 17, August 19, 2010

    When the University of Medicine and Dentistry of New Jersey (UMDNJ) hired Melanie Halpern, RN-BC...

Tip: Raise awareness of ICD-10 implications

  • CDI Strategies, Issue 17, August 19, 2010

    It may be too early to start intensive ICD-10-CM training for your coding and CDI team, but now is...

Q&A: Don't discharge the discharge summary

  • CDI Strategies, Issue 17, August 19, 2010

    Q: Should coders wait for the discharge summary before coding? A: The answer is complicated...

Tip: Use your case-mix index to help measure the effectiveness of your CDI program

  • HIM-HIPAA Insider, Issue 32, August 17, 2010

    Calculating a hospital’s case-mix index (CMI) is one way to gauge a CDI program’s...

News: CERT report points to documentation insufficiencies

  • CDI Strategies, Issue 16, August 5, 2010

    Three types of mistakes—insufficient documentation, miscoded claims, and medically...

News: Survey regarding CDI program structure garners 400 responses

  • CDI Strategies, Issue 16, August 5, 2010

    In response to a 30-question survey, 482 CDI professionals provided data about the number of staff...

Tip: Query for type, underlying causes, and/or stage of heart failure and CKD

  • CDI Strategies, Issue 16, August 5, 2010

    It’s not enough to know whether heart failure is systolic or diastolic. Congestive heart...

Q&A: Talk about potential query increases related to ICD-10 implementation

  • CDI Strategies, Issue 16, August 5, 2010

    Q: What should physicians know now about the level of specificity they’ll be required to...

Sponsored content: The art of physician education

  • CDI Strategies, Issue 16, August 5, 2010

    by Steven Robinson, RN Most physicians want to provide an accurate written picture of their...

News: IPPS Final Rule confirms DCA adjustment, kidney injury designated CC

  • CDI Strategies, Issue 16, August 5, 2010

    On July 30, CMS issued the inpatient prospective payment system (IPPS) final rule to update...

Measure the effectiveness of your CDI program

  • Briefings on Coding Compliance Strategies, Issue 8, August 1, 2010

      You’ve started a clinical documentation improvement (CDI) program and collected data...

Briefings on Coding Compliance Strategies, August 2010

  • Briefings on Coding Compliance Strategies, Issue 8, August 1, 2010

    Learn about avoidable V code traps, why you shouldn't bypass coding rules for more money, why...

News: House urges CMS to mitigate coding reduction, MedPac says stay the course

  • CDI Strategies, Issue 15, July 22, 2010

    There may be hope for hospitals carefully watching the proposed IPPS rule, praying for some...

News: Special MLN points to documentation concerns raised by RAC

  • CDI Strategies, Issue 15, July 22, 2010

    A special edition MLN Matters article released last week points to two common reasons for RAC...

News: JAMA study shows documentation of end-of-life care needs improvement

  • CDI Strategies, Issue 15, July 22, 2010

    Assessment of clinical measures associated with end-of-life treatment could actually improve care...

Special Report: 2010 ACDIS Conference, Chicago available for download

  • CDI Strategies, Issue 14, July 8, 2010

    All told there were more than 500 CDI professionals in attendance at the 2010 ACDIS National...

News: CMS releases ICD-10 implementation article

  • CDI Strategies, Issue 14, July 8, 2010

    CMS released MLN Matters Special Edition Article #SE1019 to provide updated information about the...

Tip: Understand clinical indicators of CHF before querying physicians

  • CDI Strategies, Issue 14, July 8, 2010

    Congestive heart failure (CHF) is one example of a condition for which coders and CDI specialists...

Sponsored content: The art of physician education

  • CDI Strategies, Issue 14, July 8, 2010

      by Steven Robinson, RN Most physicians want to provide an accurate written picture of...

Understand clinical indicators of CHF before querying physicians

  • HIM-HIPAA Insider, Issue 26, July 6, 2010

    Congestive heart failure (CHF) is one example of a condition for which coders and clinical...

Briefings on Coding Compliance Strategies, July 2010

  • Briefings on Coding Compliance Strategies, Issue 7, July 1, 2010

    Learn whether coders should delay sending a claim because of a missing discharge summary.

News: ICD-9-CM code updates available

  • CDI Strategies, Issue 13, June 24, 2010

    The new, revised, and deleted ICD-9-CM codes, effective October 1, 2010, are now out. You can find...

Q&A: Documentation in the discharge summary

  • CDI Strategies, Issue 13, June 24, 2010

    Q:I have a question about the discharge summary. When a physician documents a firm diagnosis (not...

Tip: Take care when crafting queries for angina

  • CDI Strategies, Issue 13, June 24, 2010

    Despite some misconceptions to the contrary, a coder may report angina, unstable (411.1) if a...

Q&A: Benchmarks for DRGs

  • CDI Strategies, Issue 13, June 24, 2010

    Q: Do you know of any recommended benchmarks or targets we should be hitting?  For example...

Sponsored Content: Target CDI challenge areas during program planning stages

  • CDI Strategies, Issue 13, June 24, 2010

    Current estimates indicate that more than 60% of all acute care hospitals have a CDI program in...

Reminder: Comments to CMS on 2011 IPPS proposed rule due June 18

  • CDI Strategies, Issue 12, June 10, 2010

    Dear ACDIS members, I want to remind you that comments to CMS on the FY 2011 IPPS proposed rule...

Sponsored Content: Target CDI challenge areas during program planning stages

  • CDI Strategies, Issue 12, June 10, 2010

    by Steven Robinson, RN Current estimates indicate that more than 60% of all acute care hospitals...

Tip: Use PEPPER reports to search for CDI targets

  • CDI Strategies, Issue 12, June 10, 2010

    The Program for Evaluating Payment Patterns Electronic Report (PEPPER) includes a wealth of...

News: Facilities cited for inappropriate billing of kyphoplasty

  • CDI Strategies, Issue 12, June 10, 2010

    Nine hospitals in seven states will pay the United States more than $9.4 million combined to...

News: North Carolina boasts the most CCDS

  • CDI Strategies, Issue 12, June 10, 2010

    by Melissa Varnavas, CPC, ACDIS associate director In the fall of 2009 Leah Taylor, RN, CCDS, and...

News: Beatty, La Rosa, Love earn 2010 CDI achievement awards

  • CDI Strategies, Issue 12, June 10, 2010

    Many CDI professionals diligently perform the day-to-day tasks of documentation improvement. And...

Director's Note: ACDIS annual conference updates

  • CDI Strategies, Issue 11, May 27, 2010

    Next week more than 500 CDI specialists from around the country will meet at the Hyatt Regency in...

Association update: CDI staffing survey results available for ACDIS members

  • CDI Strategies, Issue 11, May 27, 2010

    The ACDIS CDI Work Group is pleased to present the results of its first CDI staffing survey. The...

News: ICD-10 update available on the Web

  • CDI Strategies, Issue 11, May 27, 2010

    In April, CMS held an ICD-10 conference for software vendors, billing services, and clearinghouses...

Q&A: Policies for late entry documentation

  • CDI Strategies, Issue 11, May 27, 2010

    Q: Payers have been pushing back when a diagnosis appears in the discharge summary and not in the...

Sponsored Content: Target CDI challenge areas during program planning stages

  • CDI Strategies, Issue 11, May 27, 2010

    by Steven Robinson, RN Current estimates indicate that more than 60% of all acute care hospitals...

News: AHIMA releases CDI program guidance

  • CDI Strategies, Issue 10, May 13, 2010

    Shortly after releasing its Clinical Documentation Improvement Toolkit in April, the American...

News: CMS offers partial answer to RAC query submission questions

  • CDI Strategies, Issue 10, May 13, 2010

    CMS has been holding a number of open forum calls regarding its Recovery Audit Contractor (RAC...

News: CMS adds to the number of codes processed on institutional claims

  • CDI Strategies, Issue 10, May 13, 2010

    Effective January 1, 2011, CMS will start to accept up to 25 codes for secondary diagnoses. The...

Tip: Focus on integrity of the medical record, not coding language

  • CDI Strategies, Issue 10, May 13, 2010

    CDI specialists are getting too tied up with the minutiae of ICD-9-CM coding and DRG optimization...

AHIMA addresses physician queries in guidance for CDI programs

  • HIM-HIPAA Insider, Issue 18, May 11, 2010

    On April 29, AHIMA issued a practice brief, “Guidance for Clinical Documentation Improvement...

Q&A: Improving physician documentation in preparation for ICD-10

  • HIM-HIPAA Insider, Issue 17, May 4, 2010

    Q. What should HIM staff members communicate to physicians now about the level of specificity...

News: 2011 IPPS proposed rule released

  • CDI Strategies, Issue 9, April 29, 2010

    CMS released its fiscal year (FY) 2011 Inpatient Prospective Payment System (IPPS) proposed rule on...

News: AHIMA releases CDI Toolkit

  • CDI Strategies, Issue 9, April 29, 2010

    The American Health Information Management Association (AHIMA) published its Clinical Documentation...

Tip: Thinking of adding quality core measure review to the CDI role? Be aware of the challenges

  • CDI Strategies, Issue 9, April 29, 2010

    Despite the inclination of many hospital administrators to mechanize documentation and abstraction...

Q&A: Multiple query options can confuse syncope clarifications

  • CDI Strategies, Issue 9, April 29, 2010

    Q: Our CDI specialists tend to ask questions that provide the physician with multiple options to...

Heal the divide between HIM and CDI

  • HIM-HIPAA Insider, Issue 15, April 20, 2010

    Divisions between HIM and clinical documentation improvement (CDI) staff members are common. But in...

News: Studies, anecdotal evidence cite burden of documentation as detriment to patient care

  • CDI Strategies, Issue 8, April 15, 2010

    News: Studies, anecdotal evidence cite burden of documentation as detriment to patient care Recent...

News: GAO report says more effort needed to reduce RAC target areas

  • CDI Strategies, Issue 8, April 15, 2010

    The Government Accountability Office (GAO) offered mixed reviews of CMS’ handling of the...

News: CMS to count more codes on UB forms

  • CDI Strategies, Issue 8, April 15, 2010

    Effective January 1, 2011, CMS is expanding the number of ICD-9 diagnosis and procedure codes...

Tip: Complete full CDI assessment to make the most out of your maturing program

  • CDI Strategies, Issue 8, April 15, 2010

    So you’ve made it through the rigors of the initial CDI implementation stage. Now it’s...

Sponsored Content: Target CDI challenge areas during program planning stages

  • CDI Strategies, Issue 8, April 15, 2010

    by Steven Robinson, RN Current estimates indicate that more than 60% of all acute care hospitals...

Heal the divide between HIM and CDI

  • Medical Records Briefing, Issue 4, April 1, 2010

    Divisions between HIM and clinical documentation improvement (CDI) staff members are common. But in...

Medical Records Briefing, April 2010

  • Medical Records Briefing, Issue 4, April 1, 2010

    This month's issue includes an article on HIMs role in surviving recovery audit contractor (RAC...

The AHIMA CDI practice brief: A Q&A discussion with co-chair Gloryanne Bryant

  • CDI Strategies, Issue 7, April 1, 2010

    A CDI Work Group run by the American Health Information Management Association (AHIMA) has been...

Tip: Look for more than CMI improvement from your program metrics

  • CDI Strategies, Issue 7, April 1, 2010

    by Robert S. Gold, MD Too many organizations measure the effectiveness of their CDI program solely...

Q&A: DRG, CC, MCC target items for CDI analysis

  • CDI Strategies, Issue 7, April 1, 2010

    Q: As manager of data integrity I oversee my facility’s CDI program. Can you recommend...

Director's Note: New rooms added for 2010 ACDIS Conference; book now!

  • CDI Strategies, Issue 6, March 18, 2010

    The good news is that ACDIS has secured additional rooms at the Chicago Hyatt Regency for just $185...

News: OIG identifies nurse/physician medical record review as most effective way to identify adverse events

  • CDI Strategies, Issue 6, March 18, 2010

    In 2008, the Office of Inspector General (OIG) reviewed a sample of nearly 300 Medicare...

News: CMS offers ICD-10-CM introduction

  • CDI Strategies, Issue 6, March 18, 2010

    CMS will provide a a basic introduction to ICD-10-CM during its National Provider Conference Call...

Tip: Use AHIMA guidance as basis for CDI query processes

  • CDI Strategies, Issue 6, March 18, 2010

    Although AHIMA’s October 2008 practice brief “Managing an Effective Query...

News: CMS Transmittal focuses on physician signatures

  • CDI Strategies, Issue 6, March 18, 2010

    For CDI specialists, the physician signature is one more critical piece of documentation to keep an...

Tools: Kidney disease query forms

  • CDI Strategies, Issue 6, March 18, 2010

    Like many CDI specialists, Janice Davis, RN, clinical documentation analyst at High Point (NC...

Heal the divide between HIM and CDI

  • HIM-HIPAA Insider, Issue 10, March 16, 2010

    Divisions between HIM and clinical documentation improvement (CDI) staff members are common. But in...

Coming soon in Medical Records Briefing

  • HIM-HIPAA Insider, Issue 10, March 16, 2010

    In the April issue of MRB, you’ll find the following articles, and more! EHR beat...

Sample policy: Standard operating procedure offered for query practices

  • CDI Strategies, Issue 5, March 4, 2010

    The concept of standard operating procedures (SOP) might easily call to mind assembly lines or...

Q&A: Avoid coding confusion for TPA

  • CDI Strategies, Issue 5, March 4, 2010

    Q: Do you code the procedure for tissue plasminogen activator (tPA) administration when it is done...

News: Take RAC lessons to heart

  • CDI Strategies, Issue 5, March 4, 2010

    Those who lived through the RAC demonstration project learned valuable lessons along the way...

Reminder: ACDIS members-only Quarterly Conference call today

  • CDI Strategies, Issue 4, February 18, 2010

    The next quarterly conference call is scheduled for Thursday, February 18, 2-3 p.m. E.S.T. ACDIS...

News: Clinical documentation technology company files for bankruptcy

  • CDI Strategies, Issue 4, February 18, 2010

    Known primarily as a medical transcription and documentation firm, Tennessee-based Spheris was...

Tip: Coding for cancer

  • CDI Strategies, Issue 4, February 18, 2010

    Within the Alphabetic Index of ICD-9-CM is a Neoplasm table that assists coders in assigning...

Article of the month: Avoid sequencing oversights

  • CDI Strategies, Issue 4, February 18, 2010

    by Robert S. Gold, MD   Every so often, I come across some coding issues that recall other...

Tip: Incorporate diagnosis criteria into query forms

  • CDI Strategies, Issue 4, February 18, 2010

    ACDIS members who frequently use the CDI Talk message board already appreciate the hard work and...

Brush up on sequencing as RAC complex reviews get under way

  • HIM-HIPAA Insider, Issue 5, February 9, 2010

    As RACs begin to roll out complex reviews and request medical record documentation, compliant...

News: Texas HHS reports 'record year' in fraud/waste recovery

  • CDI Strategies, Issue 3, February 4, 2010

    In January, the Texas Health and Human Services Commission released its fiscal year 2009 annual...

News: Applications sought for CDI Professional of the Year

  • CDI Strategies, Issue 3, February 4, 2010

    The nomination period for the 2010 CDI Professional of the Year award is open through March 15...

Tip: Encourage uncertainty to help alleviate the pain of symptom DRGs

  • CDI Strategies, Issue 3, February 4, 2010

    The problem According to a recent poll on the ACDIS Web site, 85% of members cope with physicians...

News: ACDIS members' quarterly conference call next week

  • CDI Strategies, Issue 3, February 4, 2010

    The next quarterly conference call is scheduled for Thursday, February 18, 2-3 p.m. E.S.T. ACDIS...

News: ACDIS selects four new advisory board members

  • CDI Strategies, Issue 3, February 4, 2010

    With approximately 30 applications up for consideration, ACDIS had a difficult time voting in four...

News: MedPac recommends payment reductions to offset documentation improvements

  • CDI Strategies, Issue 2, January 21, 2010

    In its January release, The Medicare Payment Advisory Commission (MedPAC) recommended Congress...

News: CMS maps MS-DRGs to ICD-10

  • CDI Strategies, Issue 2, January 21, 2010

    Come October 2013, healthcare facilities will switch from reporting ICD-9-CM codes to the...

News: RACs add items to DRG validation review lists

  • CDI Strategies, Issue 2, January 21, 2010

    Connolly Healthcare, CMS’ recovery audit contractor (RAC) for Region C, announced its first...

Tip: Use January as benchmarking time

  • CDI Strategies, Issue 2, January 21, 2010

    Most organizations evaluate performance by looking at calendar year data, so set aside some time in...

Director's Note: Happy New Year! ACDIS plans for 2010, the year of the tiger

  • CDI Strategies, Issue 1, January 7, 2010

    Dear ACDIS members,   Let me begin by saying that I want to thank you all for your...

News: Add a little spice to 2010 with PEPPER reports

  • CDI Strategies, Issue 1, January 7, 2010

    Some hospitals will start to receive Program for Evaluating Payment Patterns Electronic Reports...

News: Elimination of consultation codes an opportunity for CDI specialists

  • CDI Strategies, Issue 1, January 7, 2010

    Effective January 1, CMS stopped paying for the CPT codes physicians use to bill consultations...

Tool: Documentation certificate aids physician education

  • CDI Strategies, Issue 1, January 7, 2010

    Susan Borrego, MSN, RN, CCDS, and Michelle Limo, MSMIT, RN, CCDS represent the two-person team that...

News: Compliances breaches point to CDI importance

  • CDI Strategies, Issue 26, December 24, 2009

    $3.75 million. That’s the amount California HMO Kaiser Permanente plans to pay the government...

Tip: Determine roles and goals of CDI prior to hiring staff members

  • CDI Strategies, Issue 26, December 24, 2009

    There are many schools of thought regarding which department should be in charge of a CDI...

Tool: Novant Health shares CDI 101 training video

  • CDI Strategies, Issue 26, December 24, 2009

    CDI administrators are constantly seeking simple solutions to educate fellow healthcare providers...

Q&A: Defining differences in DRG systems

  • CDI Strategies, Issue 26, December 24, 2009

    Q: What are the differences between the MS-DRG and the APR-DRG systems?  A:Garri L...

News: RACs begin complex DRG reviews

  • CDI Strategies, Issue 25, December 10, 2009

    Facilities in 10 states could soon see medical record documentation requests for complex audits...

News: CERT report of Part B billing/coding errors a good training tool for CDI specialists

  • CDI Strategies, Issue 25, December 10, 2009

    A recently-released Comprehensive Error Rate Testing (CERT) report detailing coding/billing errors...

Tip: Conduct chart reviews for ulcer documentation opportunities

  • CDI Strategies, Issue 25, December 10, 2009

    Since physicians don’t always document pressure ulcers, carefully conduct investigations of...

Tools and tips: Refresh awareness of altered mental state documentation

  • CDI Strategies, Issue 25, December 10, 2009

    In an informal ACDIS poll earlier this year CDI specialists answered the question: How well do your...

Briefings on Coding Compliance Strategies, December 2009

  • Briefings on Coding Compliance Strategies, Issue 12, December 1, 2009

    Inside: New E codes require detailed documentation OIG focuses on hot-button issues in 2010 Work...

News: Senate bill to increase RAC scope

  • CDI Strategies, Issue 24, November 26, 2009

    The Senate Healthcare Reform Bill includes a proposal for expanding the RAC program. Specifically...

Tool: Send physician documentation kudos straight to the top

  • CDI Strategies, Issue 24, November 26, 2009

    At St. Mary’s Hospital in Passaic, NJ, Melanie Halpern, RN-BC, MBA, CCDS, clinical...

Q&A: Two query alternatives for acute on chronic renal insufficiency

  • CDI Strategies, Issue 24, November 26, 2009

    Q: How I should query a physician when he documents: “Acute on chronic renal insufficiency...

Tip: Use 3rd Quarter Coding Clinic to help resolve surgery complication questions

  • CDI Strategies, Issue 24, November 26, 2009

    The American Hospital Association’s Coding Clinic for ICD-9-CM contains official advice from...

News: Four states start ZPIC reviews, others begin soon

  • CDI Strategies, Issue 23, November 12, 2009

    Health Integrity LLC, the zone four (Colorado, New Mexico, Oklahoma, and Texas) Zone Program...

News: ICD-9 to ICD-10 code conversion conference call slated for Nov. 19

  • CDI Strategies, Issue 23, November 12, 2009

    Implementation of ICD-10-CM/PCS remains three years away. But it is not too soon to find out more...

Strategy: Position your CDI role to meet the evolving world of healthcare reform

  • CDI Strategies, Issue 23, November 12, 2009

    With so much attention on healthcare reform and CMS’ shift toward paying for quality, CDI...

News: Three local CDI groups set to meet Friday, November 13

  • CDI Strategies, Issue 23, November 12, 2009

    CDI professionals across the country understand the benefit of informal, informational networking...

Q&A: Queries under RAC scrutiny

  • CDI Strategies, Issue 23, November 12, 2009

    Q: We recently heard from our process management company that after several clients have had the...

On the ACDIS Web site

  • CDI Strategies, Issue 23, November 12, 2009

    Editor’s note:The following items have been updated on the ACDIS Web site...

On the ACDIS Blog

  • CDI Strategies, Issue 23, November 12, 2009

    Editor’s note: The ACDIS Blog contains important association information as well as tips and...

Briefings on Coding Compliance Strategies, November 2009

  • Briefings on Coding Compliance Strategies, Issue 11, November 1, 2009

    Inside: Prepare for ICD-10 with anatomy/physiology education Determine your coders’ need...

Tip: Take the time to review the H&P and progress notes

  • CDI Strategies, Issue 22, October 29, 2009

    CDI specialists often underestimate the importance of the dictated history and physical (H&P...

News: Simple mistakes cause profound costs

  • CDI Strategies, Issue 22, October 29, 2009

    Sometimes documentation mistakes caught by CDI professionals are the simple ones. Like an incorrect...

Q&A: Maintaining CDI productivity under the SOI/ROM system

  • CDI Strategies, Issue 22, October 29, 2009

    Q: How has switching to a severity of illness (SOI)/ risk of mortality (ROM) system affected your...

Tip: Take time for a sepsis refresher

  • CDI Strategies, Issue 22, October 29, 2009

    Sepsis. Severe sepsis. SIRS. Septicemia. Unfortunately, this isn’t a case of “tomato...

On the ACDIS Web site

  • CDI Strategies, Issue 22, October 29, 2009

    Editor’s note:The following items have been updated on the ACDIS Web site...

On the ACDIS Blog

  • CDI Strategies, Issue 22, October 29, 2009

    Editor’s note: The ACDIS Blog contains important association information as well as tips and...

Tip: Pay attention to MACs, not just RACs

  • CDI Strategies, Issue 21, October 15, 2009

    With all the attention these days squarely on Recovery Audit Contractors (RAC), CDI specialists...

Tip: Take 2010 IPPS as temporary initiative to spur CDI initiatives

  • CDI Strategies, Issue 21, October 15, 2009

    Many hospitals feared a 1.9% reduction in payment for 2010, but they’ll actually see a 2.1...

Survey: Are queries a permanent part of the medical record?

  • CDI Strategies, Issue 21, October 15, 2009

    An HCPro Inc. poll survey posted this week asked healthcare compliance professionals if their CDI...

Briefings on Coding Compliance Strategies, October 2009

  • Briefings on Coding Compliance Strategies, Issue 10, October 1, 2009

    Inside: Use productivity benchmarks to set coding standards Roller-coaster fall results in...

News: Electronic records, query systems on their way

  • CDI Strategies, Issue 20, October 1, 2009

    Many CDI programs use Excel-spreadsheets to track and organize their query processes. More and...

News: Healthcare workers still face disruptive behavior

  • CDI Strategies, Issue 20, October 1, 2009

    CDI specialists appreciate this issue well. Understanding some of the reasons for inappropriate...

Tip: Stay up to date with quarterly Coding Clinic releases

  • CDI Strategies, Issue 20, October 1, 2009

    The most recent Coding Clinic, third quarter 2009, contains an entry on glioblastoma with vasogenic...

Coding conditions as "acute" versus "chronic"

  • HIM-HIPAA Insider, Issue 39, September 29, 2009

    Question: A patient came into the ER with complaints of a headache and facial pain. The ER...

Accurately assign POA indicators with the right info

  • HIM-HIPAA Insider, Issue 39, September 29, 2009

    The present-on-admission (POA) indicator refers to conditions that are present at the time an order...

News: CMS releases IPPS Fact Sheet

  • CDI Strategies, Issue 19, September 17, 2009

    While it may be familiar information for those working in the hospital payment world for years, CDI...

News: Medicare's HAC policy may not save much money

  • CDI Strategies, Issue 19, September 17, 2009

    For a program that spends $400 billion annually saving one or two million dollars seems like a...

Tip: Prepare for new MCCs effective October 1

  • CDI Strategies, Issue 19, September 17, 2009

    As a reminder, several new codes have been designated as complications/comorbidities (CCs) and...

Tip: Examine emergency documentation to ensure compliant coding for ARF

  • CDI Strategies, Issue 19, September 17, 2009

    The sequencing of respiratory failure depends on the reason for admission. When respiratory failure...

On the ACDIS Web site

  • CDI Strategies, Issue 19, September 17, 2009

    Editor’s note: The following items have been updated on the ACDIS Web site...

On the ACDIS Blog

  • CDI Strategies, Issue 19, September 17, 2009

    Editor’s note: The ACDIS Blog contains important association information as well as tips and...

News: Trailblazer outlines inpatient vs. observation status documentation pitfalls

  • CDI Strategies, Issue 18, September 3, 2009

    Following a targeted review of 250 claims with DRG 247, TrailBlazer, the Medicare Administrative...

TIP: Couch your query when clarifying unstable angina

  • CDI Strategies, Issue 18, September 3, 2009

    Editor’s Note: The following tip was excerpted from the article “Tips for problematic...

Clarification: Anemia documentation and coding presents communication hazards

  • CDI Strategies, Issue 18, September 3, 2009

    Editor’s note: The following Q&A first appeared in the August 20, 2009, edition of CDI...

On the ACDIS Web site

  • CDI Strategies, Issue 18, September 3, 2009

    Editor’s note: The following items have been updated on the ACDIS Web site...

Improve documentation with strong CDI specialist, program

  • HIM-HIPAA Insider, Issue 32, August 11, 2009

    By now, most coders are aware that ICD-10 will usher in expanded codes that will require additional...

News: IPPS final rule reverses reimbursement rate cut

  • CDI Strategies, Issue 16, August 6, 2009

    Concern regarding CMS’ 2010 Inpatient Prospective Payment System (IPPS) proposed rule...

Tool: CDI Program Structure benchmarking survey

  • CDI Strategies, Issue 16, August 6, 2009

    When creating a CDI program, you first have to determine its organizational structure. Will it live...

Tip: Develop a structured audit plan for CDI staff

  • CDI Strategies, Issue 16, August 6, 2009

    It's important to develop a structured process of performing quality audits of your CDI staff, says...

Improve documentation with strong CDI specialist, program

  • Briefings on Coding Compliance Strategies, Issue 8, August 1, 2009

    More hospitals will likely develop clinical documentation improvement (CDI) programs as ICD-10...

Briefings on Coding Compliance Strategies, August 2009

  • Briefings on Coding Compliance Strategies, Issue 8, August 1, 2009

    Inside: What would you do? Know your ethical obligations Improve documentation with strong CDI...

News: Hospital Compare releases readmission data for heart attack, heart failure and pneumonia

  • CDI Strategies, Issue 15, July 23, 2009

    One in five Medicare beneficiaries who leave the hospital today will re-enter the hospital within a...

Tip: Know what does, and does not, qualify as critical care

  • CDI Strategies, Issue 15, July 23, 2009

    (Editor’s note: CDI specialists may wish to provide the following tip to their physicians in...

Q&A: Impact of SOI/ROM on DRG assignment

  • CDI Strategies, Issue 15, July 23, 2009

    Q: When coded, will the five ICD-9 diagnosis codes which turn off if the patient expires for use in...

On the ACDIS Web site

  • CDI Strategies, Issue 15, July 23, 2009

    Editor’s note: The following items have been updated on the ACDIS Web site...

On the ACDIS Blog

  • CDI Strategies, Issue 15, July 23, 2009

    Editor’s note: The ACDIS Blog contains important association information as well as tips and...

News: AHIMA CDI Work Group busy researching best practices

  • CDI Strategies, Issue 14, July 9, 2009

    In April the American Health Information Management Association (AHIMA) asked for volunteers to...

Q&A: ACDIS Advisory Board weighs in on physician query form retention

  • CDI Strategies, Issue 14, July 9, 2009

    Our facility is wondering how long to keep queries. In a previous institution in which I...

On the ACDIS Blog

  • CDI Strategies, Issue 14, July 9, 2009

    Editor’s note: The ACDIS Blog contains important association information as well as tips and...

Medical Records Briefing, July 2009

  • Medical Records Briefing, Issue 7, July 1, 2009

    This month’s expanded issue includes our 4-page quarterly insert about electronic health...

News: CCDS credential updates

  • CDI Strategies, Issue 13, June 25, 2009

    Those who took the Certified Clinical Documentation Specialist (CCDS) examination in Las Vegas can...

Q&A: How should CDI programs track mortality information?

  • CDI Strategies, Issue 13, June 25, 2009

    Do established CDI programs typically track mortality rates concurrently or by trending historical...

Tip: Provide clinical updates, resources to physicians as part of your CDI duties

  • CDI Strategies, Issue 13, June 25, 2009

    Along with their daily duties of chart review, CDI specialists should consider themselves as...

On the ACDIS Web site

  • CDI Strategies, Issue 13, June 25, 2009

    On the ACDIS Web site

On the ACDIS Blog

  • CDI Strategies, Issue 13, June 25, 2009

    On the ACDIS Blog

AHA comments on payment cuts in 2010 IPPS proposed rule

  • HIM-HIPAA Insider, Issue 25, June 23, 2009

    On June 15, the American Hospital Association (AHA) provided comments to CMS about changes outlined...

On the ACDIS Blog

  • CDI Strategies, Issue 12, June 11, 2009

    Editor’s note: The ACDIS Blog contains important association information as well as tips and...

On the ACDIS Web site

  • CDI Strategies, Issue 12, June 11, 2009

    Editor’s note: The following items have been updated on the ACDIS Web site...

Q&A: Hospital Acquired Conditions and SOI/ROM levels

  • CDI Strategies, Issue 12, June 11, 2009

    Will a Hospital Acquired Condition (HAC), when coded, still affect severity of illness (SOI)/risk...

Did you know: CMS states physician query position in 2001 brief

  • CDI Strategies, Issue 12, June 11, 2009

    Government payers previously believed that physician queries opened opportunities for the...

Strategy: Multi-disciplinary documentation helps solve CHF problems

  • CDI Strategies, Issue 12, June 11, 2009

    When dealing with difficult documentation issues such congestive heart failure (CHF) consider...

News: Six cited for inadequate physician documentation

  • CDI Strategies, Issue 12, June 10, 2009

    Need to get your physicians onboard with your clinical documentation improvement program? Show them...

Sample query note: How to construct appropriate queries for bowel disease

  • CDI Strategies, Issue 11, May 28, 2009

    Sample query note: How to construct appropriate queries for bowel disease

Tip: Put on your clinical hat first, coding shoes second

  • CDI Strategies, Issue 11, May 28, 2009

    CDI specialists who seek to alter code sequences in order to optimize CC/MCC capture and case mix...

Q&A: Querying for type of heart failure

  • CDI Strategies, Issue 11, May 28, 2009

    Q: Last year a cardiologist provided an educational session for our coding auditor and the...

On the ACDIS Blog

  • CDI Strategies, Issue 10, May 14, 2009

    Editor’s note: The ACDIS Blog contains important association information as well as tips...

On the ACDIS Web site

  • CDI Strategies, Issue 10, May 14, 2009

    Editor’s note: The following items have been updated on the ACDIS Web site...

Verbal queries: Let your policies and procedures do the talking

  • CDI Strategies, Issue 10, May 14, 2009

    Verbal queries remain a source of contention for hospitals simply because these queries are...

Tip: Perform concurrent review of complication rates

  • CDI Strategies, Issue 10, May 14, 2009

    Many reported post-operative complications may not really be complications of care at all, says...

CMS issues FY 2010 IPPS proposed rule

  • HIM-HIPAA Insider, Issue 18, May 4, 2009

    The long-awaited fiscal year (FY) 2010 Inpatient Prospective Payment System (IPPS) proposed rule is...

On the ACDIS Blog

  • CDI Strategies, Issue 9, April 30, 2009

    Editor’s note: The ACDIS Blog contains important association information as well as tips and...

On the ACDIS Web site

  • CDI Strategies, Issue 9, April 30, 2009

    Editor’s note: The following items have been updated on the ACDIS Web site...

Tip: Three Rs can improve diagnosis capture, medical necessity documentation

  • CDI Strategies, Issue 9, April 30, 2009

    CDI specialists should seek to promote the three “Rs” to improve their...

Tip of the week

  • APCs Insider, Issue 16, April 17, 2009

    Everyone knows that an immense amount of teamwork is necessary for a CDI program to truly be...

On the ACDIS Blog

  • CDI Strategies, Issue 8, April 16, 2009

    On the ACDIS Blog

On the ACDIS Web site

  • CDI Strategies, Issue 8, April 16, 2009

    On the ACDIS Web site

Q&A: ACDIS Board weighs in on queries to the attending physician

  • CDI Strategies, Issue 8, April 16, 2009

    My facility’s policy requires us to address all queries to the attending physician...

Tip: Hire staff members based on expertise and professional passion

  • CDI Strategies, Issue 8, April 16, 2009

    Successful CDI programs begin with the selection of competent and cohesive teams. As CDI programs...

On the ACDIS Blog

  • CDI Strategies, Issue 7, April 2, 2009

    Editor’s Note: The ACDIS Blog allows us to post important association information as well as...

Use kidney key-words to sooth your documentation troubles

  • CDI Strategies, Issue 7, April 2, 2009

    Many physicians fail to document conditions associated with acute kidney injury (AKI) and chronic...

Tip: Elevate coder's role in concurrent reviews

  • CDI Strategies, Issue 7, April 2, 2009

    Many CDI programs use nurses as their primary concurrent reviewers, the argument being that a...

Q&A: Educating physicians on need to document chronic respiratory failure

  • CDI Strategies, Issue 7, April 1, 2009

    Other than explaining to the physician that we code chronic respiratory failure separately from the...

Tip: Consider a dedicated review of death charts

  • CDI Strategies, Issue 7, April 1, 2009

    It used to take up to three months to review medical records of expired patients in order to track...

Ten reasons for adopting an electronic query process in your CDI program

  • CDI Strategies, Issue 5, March 5, 2009

    Consider 10 reasons for adopting an electronic query process in your CDI program

ACDIS Blog: Keep up-to-date on what's going on in the association

  • CDI Strategies, Issue 5, March 5, 2009

    ACDIS Blog: Keep up-to-date on what's going on in the association

Stress synergy and collaboration to make your CDI program work

  • CDI Strategies, Issue 5, March 5, 2009

    Stress synergy and collaboration to make your CDI program work

ACDIS events: Vital networking tools available to CDI professionals

  • CDI Strategies, Issue 3, February 5, 2009

    Editor’s note: ACDIS members have access to tools and forms and a number of educational...

Q&A: Improve hospital HealthGrades with CDI

  • CDI Strategies, Issue 3, February 5, 2009

    Note: ACDIS appreciates receiving questions from our readers. We cannot promise to answer every...

News: White paper offers tour through AHIMA physician query brief

  • CDI Strategies, Issue 3, February 5, 2009

    This excerpt highlights information from the white paper, “Master physician queries...

Tip: Involve compliance officers/auditors in CDI program development

  • CDI Strategies, Issue 2, January 22, 2009

    From veteran programs to new CDI initiatives, CDI department managers should seek their...

Q&A: How to find the right physician champion

  • CDI Strategies, Issue 1, January 8, 2009

    What’s the basic role and purpose of a physician champion/advisor in a CDI program? Do you...

Strategy: Try these tips to engage physicians in your CDI program

  • CDI Strategies, Issue 1, January 8, 2009

    Consider the following techniques to improve physician education and awareness of your CDI program.

Q&A: Querying for CHF using prior documentation

  • CDI Strategies, Issue 1, January 8, 2009

    Question: Part of our clinical support for determining the presence of congestive heart failure...

Reminder: Dedicated member relations specialist added to ACDIS

  • CDI Strategies, Issue 1, January 8, 2009

    As a reminder, ACDIS has now added Susan Calabro as a full-time member relations specialist. If you...

Take ownership of patients’ background health risks

  • Medical Records Briefing, Issue 1, January 1, 2009

    We all do a great job in documenting our patients’ history and physical exams. We all...

Update physician query policy in light of new AHIMA practice brief

  • Briefings on Coding Compliance Strategies, Issue 1, January 1, 2009

    Editor’s note: Last month in BCCS, we offered an overview of AHIMA’s new query brief...

Accurately document hemorrhage severity

  • Briefings on Coding Compliance Strategies, Issue 1, January 1, 2009

    Get to know your bleeds to ensure proper coding by Robert S. Gold, MD Consider the following...

Q&A: Coding using suspected, probable diagnoses

  • CDI Strategies, Issue 25, December 11, 2008

    Where can I find documentation that says that suspected or probable diagnoses have to be in the...

News: CMS clarifies use of signature stamps

  • CDI Strategies, Issue 25, December 11, 2008

    Since CDI professionals are on the front lines of reviewing physician documentation, they should be...

Note: Bonus issue of CDI Strategies this week

  • CDI Strategies, Issue 25, December 11, 2008

    Note: Bonus issue of CDI Strategies this week

Q&A: Coding from documentation other than that of the attending physician

  • CDI Strategies, Issue 24, December 4, 2008

    When a clinical condition suggests a more specific diagnosis, and a physician from a different...

News: CMS posts Value-Based Purchasing Issues Paper

  • CDI Strategies, Issue 24, December 4, 2008

    CMS on November 25 posted an Issues Paper on its Web site relating to its plan to transition...

CMS offers RAC details despite temporary program halt

  • Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008

    Officials answer questions during special ODF By now, one point remains clear: CMS has halted the...

New guidance may create additional query opportunities

  • Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008

    Coders and CDI specialists now have concrete guidance regarding when, how, and to whom they should...

MS-DRGs on OIG radar: Ensure compliant coding

  • Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008

    Since October 1, 2007, providers have been adapting to a revised hospital inpatient reimbursement...

CMS discusses RAC expansion, ICD-10, and never events

  • Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008

    CMS discusses RAC expansion, ICD-10, and never events CMS hosted a Hospital & Hospital Quality...

Work with physicians to obtain clear-cut documentation for pressure ulcers

  • Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008

    by Robert S. Gold, MD Applying the present-on-admission (POA) indicator to pressure ulcers is no...

Assigning a POA indicator for pressure ulcers that progress from one stage to the next during a hospital stay

  • HIM-HIPAA Insider, Issue 45, November 18, 2008

    Q: What present on admission (POA) indicator should we assign when a patient presents to the...

ACDIS seeking new advisory board members

  • CDI Strategies, Issue 0, November 17, 2008

    The Association of Clinical Documentation Improvement Specialists (ACDIS) is currently seeking four...

Q&A: Pressure ulcer POA code confusion resolved

  • CDI Strategies, Issue 23, November 13, 2008

    What present on admission (POA) indicator should we assign when a patient presents to the hospital...

News: Report addresses work force needs related to EHR

  • CDI Strategies, Issue 23, November 13, 2008

    On October 20, the AMIA and AHIMA released Proposed Health Information Management and Informatics...

News: RAC delay likely temporary

  • CDI Strategies, Issue 23, November 13, 2008

    CMS has delayed the Medicare Recovery Audit Contractor (RAC) permanent program and put a moratorium...

News: White paper considered boon for CDI programs

  • CDI Strategies, Issue 23, November 13, 2008

    A recently released white paper by the Institute for Healthcare Improvement contains some sound...

ACDIS seeking new advisory board members

  • CDI Strategies, Issue 23, November 13, 2008

    ACDIS seeking new advisory board members

Get a bloody good understanding of GI hemorrhage

  • Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008

    Gastrointestinal (GI) bleed and its manifestations can be confusing without some insight into...

Clear up morphology and neoplasm code confusion

  • Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008

    The ICD-9-CM Manual provides many helpful tools you can use to your advantage. For example, despite...

Brush up on the 2009 ICD-9-CM carcinoid codes

  • Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008

    Most surgeons find carcinoid tumors incidentally, either during the postmortem exam when a patient...

Examine postoperative condition coding

  • Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008

    Just because a physician documents a condition during the postoperative period doesn’t mean...

One-day stays

  • Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008

    Forty percent of Medicare admission denials relate to improper one-day stays. If this statistic...

News: Need to query for acute CHF lessened, thanks to new Coding Clinic

  • CDI Strategies, Issue 22, October 30, 2008

    The third quarter, 2008 AHA Coding Clinic for ICD-9-CM contains valuable new guidance for CDI...

Q&A: ACDIS advisory panel members answer questions about chart reviews, staffing

  • CDI Strategies, Issue 22, October 30, 2008

    Are there any standards about how many records to review per day? How about staffing size?

News: OIG targets MS-DRGs upcoding in 2009 Work Plan

  • CDI Strategies, Issue 22, October 29, 2008

    Since October 1, 2007, Medicare providers have been adapting to a revised hospital inpatient...

News: CMS announces permanent RAC contractors

  • CDI Strategies, Issue 21, October 16, 2008

    CMS announced the new Medicare Recovery Audit Contractors (RACs) for its permanent nationwide...

Data gathering/reporting: One CDI specialist shares her hospital's methodology

  • CDI Strategies, Issue 21, October 16, 2008

    The CDI team at South Shore Hospital (SSH) in Weymouth, MA, has been tracking results of its...

Strategy: Put the "clinical" back in clinical documentation review

  • CDI Strategies, Issue 21, October 16, 2008

    Too many CDI specialists focus strictly on DRG assignment when reviewing medical records when they...

News: ACDIS spearheads the development of a professional certification

  • CDI Strategies, Issue 20, October 2, 2008

    ACDIS members are looking for professional recognition, further definition of their competencies...

News: CMS updates HAC and POA section of Web site

  • CDI Strategies, Issue 20, October 2, 2008

    CMS recently updated all sections of the Hospital-Acquired Conditions (HAC) and Present on...

News: AHIMA releases long-awaited final physician query practice brief

  • CDI Strategies, Issue 20, October 2, 2008

    The American Health Information Management Association (AHIMA) on Sept. 29 released its...