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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 26, December 23, 2010

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

  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

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

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

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

• News: 2010 RAC Preparedness Benchmarking Report released

  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

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

• Tip: Take some time to update your CDI program with an eye toward compliance

  When evaluating overall compliance within a CDI department, Lynne Spryszak, RN, CCDS, CPC-A, CDI...

• Tip: Thoughts for how to develop CDI metrics

  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

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

Issue 25, December 9, 2010

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

  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

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

• News: Comment period for ACOs closes

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

• News: AHIMA releases recertification guidelines for ICD-10

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

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

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

• Sponsored Content: Incorporate quality mandates into the CDI function

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

• News: DOJ recovers record $3 billion from fraud claims

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

Issue 24, November 24, 2010

• News: CMS publishes 2011 RAC ADR limits for providers

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

• ACDIS seeking advisory board applicants by Dec. 1 deadline

  ACDIS is currently seeking four new ACDIS members to join its national advisory board in 2011...

• News: Polls illustrate CDI programs seek RN staff

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

• News: ACDIS blog post estimates between 3,000-4,000 CDI staff employed nationally

  Recently, Robert S. Gold, MD, estimated that 60% of facilities nationwide implemented CDI programs...

• Updates to the ACDIS website

  The ACDIS Forms & Tools library is now organized into the following sections to make it easier...

• Sponsored Content: Incorporate quality mandates into the CDI function

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

Issue 23, November 11, 2010

• Membership update: 2010 physician query benchmarking survey launched

  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

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

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

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

• AHIMA releases ethics guidance for CDI professionals

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

• Tool: Body Mass Index documentation reminder flyer

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

• Updates on the ACDIS website

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

• Sponsored Content: Incorporate quality mandates into the CDI function

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

Issue 22, October 28, 2010

• News: Partial freeze of code changes announced

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

• News: Sepsis survivors face future health problems

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

• Tip: Cirrhosis and alcoholic hepatitis

  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

  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

  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

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

Issue 21, October 14, 2010

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

  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

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

• News: Kaiser donates medical terminology database to HHS

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

• Tip: What to include in a homegrown analysis of CDI

  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?

  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

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

Issue 20, September 30, 2010

• Tip: Anatomy to know when capturing debridement documentation

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

• News: Use OIG compliance tips for ICD-10 implementation

  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

  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

  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

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

Issue 19, September 16, 2010

• News: Inpatient admissions decision fuels RAC uncertainty

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

• Column: AKI and the mess we're in

  Why AKI was demoted to CC status by CMS By Robert S. Gold, MD In March 2008, the National Kidney...

• Tip: Pay attention to query retention

  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

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

• Sponsored content: The art of physician education

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

Issue 18, September 2, 2010

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

  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

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

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

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

• Tip: Audit records for signature documentation

  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

  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

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

Issue 17, August 19, 2010

• Director's Note: Speakers sought for ACDIS 2011 conference

  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

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

• Tool: Alternative staff schedules offer CDI opportunities

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

• Tip: Raise awareness of ICD-10 implications

  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

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

• Sponsored content: The art of physician education

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

Issue 16, August 5, 2010

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

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

• News: CERT report points to documentation insufficiencies

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

• News: Survey regarding CDI program structure garners 400 responses

  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

  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

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

• Sponsored content: The art of physician education

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

Issue 15, July 22, 2010

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

  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

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

• Survey: Production expectations for reviews, re-reviews

  A recent ACDIS survey available to members shows that most CDI programs require specialists to...

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

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

• Q&A: AKI/renal failure confusion continues

  Q: I am very confused about the diagnosis of acute renal injury/acute renal failure. I know that...

Issue 14, July 8, 2010

• Special Report: 2010 ACDIS Conference, Chicago available for download

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

• News: CMS releases ICD-10 implementation article

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

• Tip: Understand clinical indicators of CHF before querying physicians

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

• Tip: Differentiate between bacteremia, septicemia coding

  Over the years all authoritative coding sources referred to sepsis and septicemia as the same...

• Q&A: Know what to target when tracking top DRGs

  Q: Can you recommend specifically what MS-DRGs are best to review and track or what CCs we should...

• Sponsored content: The art of physician education

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

Issue 13, June 24, 2010

• News: ICD-9-CM code updates available

  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

  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

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

• Q&A: Benchmarks for DRGs

  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

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

Issue 12, June 10, 2010

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

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

• News: North Carolina boasts the most CCDS

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

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

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

• Tip: Use PEPPER reports to search for CDI targets

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

• News: Facilities cited for inappropriate billing of kyphoplasty

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

• Sponsored Content: Target CDI challenge areas during program planning stages

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

Issue 11, May 27, 2010

• Director's Note: ACDIS annual conference updates

  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

  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

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

• Q&A: Policies for late entry documentation

  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

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

Issue 10, May 13, 2010

• News: AHIMA releases CDI program guidance

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

• News: CMS offers partial answer to RAC query submission questions

  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

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

• Sponsored Content: Target CDI challenge areas during program planning stages

  Editor’s note: Beginning with the April 2010 edition of CDI Journal, Maxim Health...

Issue 9, April 29, 2010

• News: 2011 IPPS proposed rule released

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

• News: AHIMA releases CDI Toolkit

  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

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

• Tip: Add physician education elements to your query/clarification forms

  Many CDI specialists struggle with the problem of educating physicians about documentation...

• Q&A: Multiple query options can confuse syncope clarifications

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

Issue 8, April 15, 2010

• News: Studies, anecdotal evidence cite burden of documentation as detriment to patient care

  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

  The Government Accountability Office (GAO) offered mixed reviews of CMS’ handling of the...

• Tip: Watch for postop or post-traumatic infections with OR procedures

  CDI specialists would do well to keep an eye on documentation leading to three MS-DRGs that...

• News: CMS to count more codes on UB forms

  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

  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

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

Issue 7, April 1, 2010

• Director's Note: Early registration deadline for conference tomorrow

  There are roughly 60 days left until the third annual ACDIS conference but only two to make the...

• The AHIMA CDI practice brief: A Q&A discussion with co-chair Gloryanne Bryant

  A CDI Work Group run by the American Health Information Management Association (AHIMA) has been...

• Tip: Ensure 'complete' medical record documentation

  by Glen Krauss, RHIA  A 2007 study in the Journal of the American Medical Association found...

• Tip: Look for more than CMI improvement from your program metrics

  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

  Q: As manager of data integrity I oversee my facility’s CDI program. Can you recommend...

Issue 6, March 18, 2010

• Director's Note: New rooms added for 2010 ACDIS Conference; book now!

  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

  In 2008, the Office of Inspector General (OIG) reviewed a sample of nearly 300 Medicare...

• News: CMS offers ICD-10-CM introduction

  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

  Although AHIMA’s October 2008 practice brief “Managing an Effective Query...

• News: CMS Transmittal focuses on physician signatures

  For CDI specialists, the physician signature is one more critical piece of documentation to keep an...

• Tools: Kidney disease query forms

  Like many CDI specialists, Janice Davis, RN, clinical documentation analyst at High Point (NC...

Issue 5, March 4, 2010

• News: 2009 CDI Salary Survey available

  More than 300 CDI specialists participated in the 2009 ACDIS salary survey. Respondents answered...

• Sample policy: Standard operating procedure offered for query practices

  The concept of standard operating procedures (SOP) might easily call to mind assembly lines or...

• Tip: Stay on the right CDI track by querying when appropriate

  CDI specialists are charged with reviewing concurrent medical records on the hospital floor and...

• Q&A: Avoid coding confusion for TPA

  Q: Do you code the procedure for tissue plasminogen activator (tPA) administration when it is done...

• News: Take RAC lessons to heart

  Those who lived through the RAC demonstration project learned valuable lessons along the way...

Issue 4, February 18, 2010

• Reminder: ACDIS members-only Quarterly Conference call today

  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

  Known primarily as a medical transcription and documentation firm, Tennessee-based Spheris was...

• Tip: Coding for cancer

  Within the Alphabetic Index of ICD-9-CM is a Neoplasm table that assists coders in assigning...

• Article of the month: Avoid sequencing oversights

  by Robert S. Gold, MD   Every so often, I come across some coding issues that recall other...

• Tip: Incorporate diagnosis criteria into query forms

  ACDIS members who frequently use the CDI Talk message board already appreciate the hard work and...

• The secret to CDI success: Teach physicians to document decision making

  When CDI programs fail it’s typically due to a lack of physician involvement, says Glenn...

Issue 3, February 4, 2010

• News: ACDIS selects four new advisory board members

  With approximately 30 applications up for consideration, ACDIS had a difficult time voting in four...

• News: Texas HHS reports 'record year' in fraud/waste recovery

  In January, the Texas Health and Human Services Commission released its fiscal year 2009 annual...

• News: Applications sought for CDI Professional of the Year

  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

  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

  The next quarterly conference call is scheduled for Thursday, February 18, 2-3 p.m. E.S.T. ACDIS...

• Q&A: Sepsis vs. SIRS

  Q: A patient with a urinary tract infection appeared septic, and she also fit the criteria for...

Issue 2, January 21, 2010

• News: MedPac recommends payment reductions to offset documentation improvements

  In its January release, The Medicare Payment Advisory Commission (MedPAC) recommended Congress...

• News: CMS maps MS-DRGs to ICD-10

  Come October 2013, healthcare facilities will switch from reporting ICD-9-CM codes to the...

• News: RACs add items to DRG validation review lists

  Connolly Healthcare, CMS’ recovery audit contractor (RAC) for Region C, announced its first...

• Tip: Use January as benchmarking time

  Most organizations evaluate performance by looking at calendar year data, so set aside some time in...

Issue 1, January 7, 2010

• Director's Note: Happy New Year! ACDIS plans for 2010, the year of the tiger

  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

  Some hospitals will start to receive Program for Evaluating Payment Patterns Electronic Reports...

• News: Elimination of consultation codes an opportunity for CDI specialists

  Effective January 1, CMS stopped paying for the CPT codes physicians use to bill consultations...

• Tip: Maintain sepsis focus under RAC scrutiny

  Septicemia has been problematic for some time. Coders often misunderstand the ICD-9-CM Official...

• Tool: Documentation certificate aids physician education

  Susan Borrego, MSN, RN, CCDS, and Michelle Limo, MSMIT, RN, CCDS represent the two-person team that...