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CDI Strategies

CDI Strategies is a free bi-weekly e-mail resource for CDI specialists and Association of Clinical Documentation Improvement Specialists (ACDIS) members. CDI Strategies offers biweekly news on the latest coding changes and regulatory updates as well as tips for day to day program improvement and problem-solving.

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CDI Strategies

Issue 25, December 11, 2008

• Note: Bonus issue of CDI Strategies this week

  Note: Bonus issue of CDI Strategies this week

• News: CMS clarifies use of signature stamps

  Since CDI professionals are on the front lines of reviewing physician documentation, they should be...

• Q&A: Coding using suspected, probable diagnoses

  Where can I find documentation that says that suspected or probable diagnoses have to be in the...

Issue 24, December 4, 2008

• News: CMS to discuss HACs Dec. 18

  CMS will hold a "listening session" regarding hospital acquired conditions in inpatient...

• Q&A: Coding from documentation other than that of the attending physician

  When a clinical condition suggests a more specific diagnosis, and a physician from a different...

• News: CMS posts Value-Based Purchasing Issues Paper

  CMS on November 25 posted an Issues Paper on its Web site relating to its plan to transition...

Issue 23, November 13, 2008

• ACDIS seeking new advisory board members

  ACDIS seeking new advisory board members

• News: White paper considered boon for CDI programs

  A recently released white paper by the Institute for Healthcare Improvement contains some sound...

• News: RAC delay likely temporary

  CMS has delayed the Medicare Recovery Audit Contractor (RAC) permanent program and put a moratorium...

• News: Report addresses work force needs related to EHR

  On October 20, the AMIA and AHIMA released Proposed Health Information Management and Informatics...

• Q&A: Pressure ulcer POA code confusion resolved

  What present on admission (POA) indicator should we assign when a patient presents to the hospital...

Issue 22, October 30, 2008

• ACDIS welcomes new associate director

  ACDIS welcomes new associate director

• Q&A: ACDIS advisory panel members answer questions about chart reviews, staffing

  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

  Since October 1, 2007, Medicare providers have been adapting to a revised hospital inpatient...

• News: Need to query for acute CHF lessened, thanks to new Coding Clinic

  The third quarter, 2008 AHA Coding Clinic for ICD-9-CM contains valuable new guidance for CDI...

Issue 21, October 16, 2008

• News: CMS announces permanent RAC contractors

  CMS announced the new Medicare Recovery Audit Contractors (RACs) for its permanent nationwide...

• Strategy: Put the "clinical" back in clinical documentation review

  Too many CDI specialists focus strictly on DRG assignment when reviewing medical records when they...

• Data gathering/reporting: One CDI specialist shares her hospital's methodology

  The CDI team at South Shore Hospital (SSH) in Weymouth, MA, has been tracking results of its...

Issue 20, October 2, 2008

• News: ACDIS spearheads the development of a professional certification

  ACDIS members are looking for professional recognition, further definition of their competencies...

• News: AHIMA releases long-awaited final physician query practice brief

  The American Health Information Management Association (AHIMA) on Sept. 29 released its...

• News: CMS updates HAC and POA section of Web site

  CMS recently updated all sections of the Hospital-Acquired Conditions (HAC) and Present on...

Issue 19, September 18, 2008

• News: October 2008 CDI Journal available for ACDIS members to download

  October 2008 CDI Journal available for ACDIS members to download

• Pop quiz: Querying for the POA indicator

  Pop quiz: Querying for the POA indicator

• Q&A: Coder vs. clinical documentation specialist queries: ACDIS advisory panel members weigh in

  Q&A: Coder vs. clinical documentation specialist queries: ACDIS advisory panel members weigh in

• News: CMS revises timeline for national RAC rollout

  News: CMS revises timeline for national RAC rollout

Issue 18, September 4, 2008

• News: ACDIS welcomes dedicated member relations specialist

  News: ACDIS welcomes dedicated member relations specialist

• Tip: Be creative when obtaining physician buy-in for a CDI program

  Tip: Be creative when obtaining physician buy-in for a CDI program

• Strategy: Expand your CDI horizons by examining medical necessity of inpatient stays

  Strategy: Expand your CDI horizons by examining medical necessity of inpatient stays

• Q&A: Members of ACDIS advisory board offer advice on querying for malnutrition

  Q&A: Members of ACDIS advisory board offer advice on querying for malnutrition

Issue 17, August 21, 2008

• News: Updated ICD-9-CM Official Guidelines for Coding and Reporting contain several changes that impact clinical documentation specialists

  News: Updated ICD-9-CM Official Guidelines for Coding and Reporting contain several changes that...

• News: HHS announces timeline for transition to ICD-10-CM

  News: HHS announces timeline for transition to ICD-10-CM

• Q&A: Members of ACDIS advisory board offer advice on queries

  Q&A: Members of ACDIS advisory board offer advice on queries

Issue 16, August 7, 2008

• 2009 IPPS final rule reflects a continued need for strong CDI programs

  2009 IPPS final rule reflects a continued need for strong CDI programs

Issue 15, July 24, 2008

• ACDIS seeking speakers for 2009 Annual Conference

  ACDIS seeking speakers for 2009 Annual Conference

• Tip: Get physicians on board by providing CERT education

  Tip: Get physicians on board by providing CERT education

• ACDIS 2009 conference speaker questionnaire

  ACDIS 2009 conference speaker questionnaire

• Q&A: Structuring a CDI specialist's work day

  Q&A: Structuring a CDI specialist’s work day

• News: CMS issues press release announcing nearly $700 million in improper Medicare payments recovered by Recovery Audit Contractors

  News: CMS issues press release announcing nearly $700 million in improper Medicare payments...

Issue 14, July 10, 2008

• Q&A: Clinical documentation specialist vs. coder queries: Two ACDIS members provide their thoughts

  Q&A: Clinical documentation specialist vs. coder queries: Two ACDIS members provide their...

• Tip: Understand official definition of principal diagnosis

  Tip: Understand official definition of principal diagnosis

• Strategy: Analyze various parts of the medical record to determine present on admission (POA) status

  Strategy: Analyze various parts of the medical record to determine present on admission (POA) status

Issue 13, June 26, 2008

• Strategy: Ensure coverage of weekends with CDI staffing plan

  Strategy: Ensure coverage of weekends with CDI staffing plan

• Q&A: Approaching busy physicians

  Q&A: Approaching busy physicians

• Tip: Consider these three ground rules for getting coders and CDI specialists on the same page

  Tip: Consider these three ground rules for getting coders and CDI specialists on the same page

Issue 12, June 12, 2008

• Tip: Querying physicians regarding pneumonia's causative agent

  Tip: Querying physicians regarding pneumonia's causative agent

• Strategy: Consider the benefits of a CDI specialist in the ED

  Strategy: Consider the benefits of a CDI specialist in the ED

• News: CMS to challenge successfully appealed RAC denials, AHA News Now reports

  News: CMS to challenge successfully appealed RAC denials, AHA News Now reports

Issue 11, May 29, 2008

• Tip: Watch for new ICD-9-CM pressure ulcer codes and their impending impact on MS-DRG assignment

  Watch for new ICD-9-CM pressure ulcer codes and their impending impact on MS-DRG assignment

• News: New AHIMA physician query practice brief causes concern amongst CDI specialists

  News: New AHIMA physician query practice brief causes concern amongst CDI specialists

Issue 10, May 14, 2008

• Q&A: Physician documentation of troponin leak

  Q&A: Physician documentation of troponin leak

• Tip: Tie in national health observances to your documentation improvement efforts

  Tip: Tie in national health observances to your documentation improvement efforts

• Tip: Assign POA carefully, based on treating practitioner's documentation involved in patient's care

  Tip: Assign POA carefully, based on treating practitioner’s documentation involved in...

Issue 9, May 1, 2008

• News: AAHAM supports one-year moratorium on RAC program

  News: AAHAM supports one-year moratorium on RAC program

• Tip: Narrow the focus of your physician education

  Tip: Narrow the focus of your physician education

• Q&A: Measuring the dollar impact of CDI

  Q&A: Measuring the dollar impact of CDI

Issue 8, April 17, 2008

• News: CMS releases 2009 Inpatient Prospective Payment System (IPPS) proposed rule

  News: CMS releases 2009 Inpatient Prospective Payment System (IPPS) proposed rule

• Q&A: CHF vs. cor pulmonale

  Q&A: CHF vs. cor pulmonale

• Don't rely on paper queries: Engage physicians in dialogue

  Don’t rely on paper queries: Engage physicians in dialogue

Issue 7, April 3, 2008

• Hospital data continues trend toward increased public availability

  Hospital data continues trend toward increased public availability

• Helpful links for CDI specialists

  Following are some Web-based resources that ACDIS members have recommended as being helpful for CDI...

• Q/A: Querying physicians regarding rheumatic heart disease

  Q/A: Querying physicians regarding rheumatic heart disease

Issue 6, March 20, 2008

• Shake up the routine in your CDI efforts

  Shake up the routine in your CDI efforts

• Q&A: ACDIS advisory panel members answer questions about electronic records, POA

  Q&A: ACDIS advisory panel members answer questions about electronic records, POA

Issue 5, March 6, 2008

• News: CMS announces identification of $371.5 million in improper Medicare payments through Recovery Audit Contractor (RAC) program

  News: CMS announces identification of $371.5 million in improper Medicare payments through Recovery...

• Tip: Watch for "clinical perception" errors related to present on admission reporting, involve CDI specialists in education

  Tip: Watch for "clinical perception" errors related to present on admission reporting, involve CDI...

• Editorial: Use technology as a tool and not a crutch in your CDI program

  Editorial: Use technology as a tool and not a crutch in your CDI program

Issue 4, February 21, 2008

• News: Remark code N363 and the present on admission indicator

  News: Remark code N363 and the present on admission indicator

• Q&A: Faxing physician queries (three perspectives)

  Q&A: Faxing physician queries (three perspectives)

• Q&A: Coding BMI from a dietician's note

  Q&A: Coding BMI from a dietician's note

Issue 3, February 7, 2008

• News: Three New Jersey hospitals make headlines for allegedly defrauding Medicare

  News: Three New Jersey hospitals make headlines for allegedly defrauding Medicare

• Strategy: Focus on emergent cases

  Strategy: Focus on emergent cases

• Tip: Strengthen physician documentation of problematic diagnoses

  Tip: Strengthen physician documentation of problematic diagnoses

Issue 2, January 24, 2008

• Strategy: Establish a daily workflow for your CDI specialists

  Strategy: Establish a daily workflow for your CDI specialists

• Tip: Query when treatment/monitoring of patient supports the question

  Tip: Query when treatment/monitoring of patient supports the question

• Q&A: Present on admission claims and the "U" indicator

  Q&A: Present on admission claims and the "U" indicator

Issue 1, January 10, 2008

• News: Office of Inspector General releases its semiannual report for the second half of fiscal year 2007

  News: Office of Inspector General releases its semiannual report for the second half of fiscal year...

• Tip: Uncover the hidden clues in physician documentation

  Tip: Uncover the hidden clues in physician documentation

• Strategy: Look to official ICD-9-CM guidelines for examples of compliant queries

  Strategy: Look to official ICD-9-CM guidelines for examples of compliant queries