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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 11, May 24, 2012

• Director's Note: 5th annual ACDIS conference a success

  Thank you to the more than 800 attendees and two dozen exhibitors who took part in the 5th Annual...

• Membership update: Quarterly Conference Call Thursday

  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

  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

  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

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

• Tip: Add a little 'MUSIC' to documentation reviews

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

• Q&A: Clinical conversations vs. leading queries

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

Issue 10, May 10, 2012

• Director's Note: 5th Annual ACDIS Conference underway

  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

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

• News: Celebrate National Nurses Week!

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

• News: CMS releases latest compliance newsletter

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

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

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

• White Paper: Mastering the three-day payment rule

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

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

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

Issue 9, April 26, 2012

• News: IPPS proposed rule expands VBP, increases IPPS payment

  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

  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

  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

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

• News: CMS adds spending per beneficiary to Hospital Compare data

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

• Q&A: Anesthesia records and querying for blood transfusion

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

Issue 8, April 12, 2012

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

  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

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

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

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

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

  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

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

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

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

• Q&A: Clarifying ’septic shock’

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

Issue 7, March 29, 2012

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

  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

  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

  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

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

• News: CMS delays HIPAA Version 5010 enforcement date

  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

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

• News: OIG says CMS overestimates payment error rates

  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.

  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

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

Issue 6, March 15, 2012

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

  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

  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

  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

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

• News: Quality Forum leader to step down

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

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

  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.’

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

• Tip: Take advantage of nutrition month for your physician training

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

• Q&A: Code or query for clinical significance?

  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

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

Issue 5, March 1, 2012

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

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

• Membership Update: Quarterly Conference Call recording posted

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

• News: Sample VBP reports available on QualityNet

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

• News: PEPPER ready for review

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

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

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

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

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

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

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

Issue 4, February 16, 2012

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

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

• Membership Update: Facebook sites consolidated

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

• News: CMS releases first quarter report regarding Recovery Audit Program

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

• News: Nations largest insurers change physician payments

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

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

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

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

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

• News: Boston facility investigated for inappropriate billing

  Boston’s Beth Israel Deaconess hospital is the latest facility to succumb to investigations...

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

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

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

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

Issue 3, February 2, 2012

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

  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

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

• News: Poll, survey indicates CDI salary range

  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

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

• News: Study finds physicians need more help with electronic records

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

• News: Nurses spending more time on indirect patient care

  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

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

• Membership Update: Quarterly conference calls dates announced

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

Issue 2, January 19, 2012

• News: Advisory Board voting to begin next week

  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

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

• Membership Update: New Local Chapter page published

  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

  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

  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

  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

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

Issue 1, January 5, 2012

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

  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

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

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

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

• News: MAC notice underscores importance of good documentation through the medical record

  CDI specialists ideally should review medical records in their entirety and clarify non-specific...

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

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

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

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

• Pre-conference event: Physician advisor session expanded

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

• Conference opportunity: Poster submissions open for 2012 ACDIS conference

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

• Networking opportunities

  There's no better way to celebrate the New Year than with these educational opportunities. Make...