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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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Issue 20, May 19, 2016

• A Note from the ACDIS Director: The passing of an industry great

  Robert S. Gold, 1942-2016 If you’ve ever read an issue of HCPro’s flagship...

• A Note from the Associate Editorial Director: Future memory making in progress

  Nine years. Nine conferences. Each is distinctive. Those fortunate enough to attend conferences...

• Conference Update: See you next week in Atlanta!

  Wow. Somehow, it is already that time. The 2016 ACDIS Conference is finally here. After...

• News: Does Measuring Quality Really Ensure Patient Safety?

  Healthcare lacks valid patient safety measures even though much—from reimbursement to...

• News: Hospital billing data no reflection of safety records

  Data used to gauge and rank the safety of hospitals are woefully inaccurate, according to Johns...

• News: CMS revises 14 NCDs in coding maintenance update

  CMS recently released its seventh maintenance update for National Coverage Determinations (NCD) to...

• Q&A: Sepsis as a primary diagnosis

  Q: If a physician documents sepsis due to decubitus ulcer and UTI due to indwelling catheter, can...

• Local Chapter Update: Connect with peers from your home state at ACDIS

  It’s tradition. Day 1 of the annual conference is ACDIS pride day, where attendees are...

Issue 19, May 12, 2016

• A Note from an Attendee: Why I attend the ACDIS Conference

  by Robin Deakins, RN, CCDS It all started with my desire to attend the 2015 ACDIS conference...

• Conference Update: Less than two weeks away!

  The ACDIS office is in official final countdown mode— shipments are being wrapped, room...

• News: Revamped ACDIS website coming soon

  The Association of Clinical Documentation Improvement Specialists (ACDIS) will soon be launching a...

• News: CMS previews new Simple Choice Plans and quality ratings

  With the fourth year of open enrollment for Affordable Care Act (ACA) marketplace health plans just...

• News: OIG Kwashiorkor scrutiny continues

  The Office of the Inspector General (OIG) continues to target fraudulent Kwashiorkor claims. This...

• News: Understanding malnutrition for positive patient outcomes

  Malnutrition has historically been an issue in facilities, mainly because before 2012, no...

• Q&A: Coding versus clinical conventions

  Q: When I try to code ileostomy take down of the small bowel resection and end-to-end anastomosis I...

• Local Chapter Update: Upcoming meetings and events

  A list of upcoming meetings and events for our local chapters. 

Issue 18, May 5, 2016

• A Note from the ACDIS Director: The best CDI has to offer

  I’m asked from time to time what excites me most about the ACDIS conference. Perhaps at one...

• Conference Update: The final countdown begins

  Can you believe it? We’re already just over two weeks until the 9th Annual ACDIS...

• News: CMS' Proposed physician payment model consolidates, customizes quality initiatives

  Just as government healthcare reimbursement methods continue to evolve on the inpatient side...

• News: National agency changes terminology associated with pressure ulcers

  It seems change lurks near every corner we turn this year. While not every change results in...

• Tip: Non-members pre-register for the new ACDIS site now!

  ACDIS will soon be launching a new and improved website. We will continue to provide certain free...

• Q&A: Code assignment for hospital acquired/healthcare associated conditions

  Q: Is it appropriate to assign code Y95, nosocomial condition, based on the documentation of...

• Local Chapter Update: Upcoming meetings

  Here's what's happening with our local chapters. 

• Certification Update: ACDIS announces a policy and penalty fees for late CCDS recertification

  Effective July 1, 2016, ACDIS will institute a policy and penalty fee for late Certified Clinical...

Issue 17, April 28, 2016

• A Note from the Associate Director: Growing the CDI profession

  By: Melissa Varnavas As you read this, the ACDIS administrative team may likely be ensconced in a...

• News: MS-DRG assignment changes included in IPPS proposed rule

  It shouldn’t come as a surprise that the fiscal year 2017 inpatient prospective payment...

• News: Audit activity set to pick up pace in 2016

  This will be a big year for audits between the new Recovery Auditors hitting the ground later this...

• News: Safe use of copy/paste functionality

  Electronic health records may provide a number of benefits such as improving the continuity of care...

• Q&A: Respiratory failure as a result of an overdose

  Q: When a patient does presents in acute respiratory failure, as well as overdose, is it ever...

• Local Chapter Update: Online toolkit offers meeting tips for leaders

  The online local chapter pages offer a wealth of information for those interested in getting to...

• Conference Update: Less than a month away

  The conference is just 25 days away! If you haven’t registered yet, there’s still...

Issue 16, April 21, 2016

• A Note from the CCDS Coordinator: Onsite scoring live now

  by Penny Richards  Live onsite scoring for the CCDS exam began again last Friday, April 15...

• News: IPPS proposed rule released

  CMS issued the fiscal year (FY) 2017 IPPS proposed rule yesterday with updates to several quality...

• News: E/M services remain a leading cause of improper Medicare payments

  Evaluation and management (E/M) services payments—the principal payment method for...

• News: Volunteer physician payment experiment launched

  CMS launched a voluntary five-year physician payment program dubbed the Comprehensive Primary...

• Tip: Can technology bridge the gap for new sepsis criteria?

  Organizations should be able to mine computer-assisted coding (CAC) or EHR software to identify...

• Q&A: Coding and sequencing clarification

  Q: I have a patient with Stage 4 lung cancer that presented with fatigue, cough, and loss of...

• Local Chapter Update: Upcoming meetings and events

  If you are interested in joining a local chapter remember to complete the short online...

• Conference Update: Just over a month to go

  The conference is just 35 days away, and if you are among the more than 1,400 people who have...

Issue 15, April 14, 2016

• A Note from the ACDIS Editor: Thanks for getting social with us!

  by Katy Rushlau For those of you who follow ACDIS on social media—yes, we’re...

• News: CMS demonstrates how to maintain ICD-10 progress

  An infographic newly released by CMS guides healthcare providers toward better assessing...

• Tip: Five questions for CDI to consider regarding new sepsis criteria

  by Amy Czahor, RHIT, CCS, CDIP On February 23, the Journal of the American Medical...

• Q&A: How many people should be involved in reviewing a medical record?

  Q: How many people should be involved in reviewing a medical record?

• Local Chapter Update: Upcoming events and meetings

  If you are interested in joining a local chapter remember to complete the short online...

• Conference Update: Are you a CDI manager or leader and looking for networking opportunities?

  Are you in CDI leadership and looking for national networking opportunities? Consider participating...

Issue 14, April 7, 2016

• A Note from the Associate Editorial Director: Physician advisors as part of the CDI team

  It’s been five years since we surveyed the ACDIS members regarding the role physician...

• News: Coding Clinic reverses stance on heart failure code assignment

  Coders can now appropriately assign a code for diastolic or systolic heart failure, as warranted if...

• News: Coding changes on the horizon; CMS starts clearing ICD-10 code freeze backlog

  3,600 new procedure codes. 1,900 new diagnosis codes. 487 code revisions. That’s what’s...

• News: Hospices inappropriately billed Medicare over $250 million for general inpatient care

  Recent investigations by the Office of Inspector General (OIG) have shown a number of instances in...

• News: CMS discussion paper highlights changes to risk adjustment program

  Federal regulators are considering changes to the Affordable Care Act’s Hierarchical...

• Meet a Member: Australian woman brings CDI ’down under’

  At ACDIS, it’s no surprise when we hear about clinical documentation improvement efforts...

• Q&A: Leading multiple-choice queries

  Q: We are currently using a hybrid medical record, so we have standard query forms with...

• Local Chapter Update: Upcoming meetings and events

  The month of April promises a number of educational opportunities for CDI professionals across the...

• Conference Update: Get social with us

  The conference is next month and the ACDIS office is buzzing with excitement. Our staff...

Issue 13, March 31, 2016

• A Note from the Director: ACDIS Advisory Board responds to new definitions of sepsis, septic shock

  By: Brian Murphy As reported in the March 3 edition of CDI Strategies a joint U.S...

• News: Hospital system appeal for mandamus order on HHS denied

  Another hospital lost its attempt to push through the backlog of denied claims appeals recently...

• News: The CDI leader’s keys to success: Solid partnerships, driving improvements

  In 2014, 66% of 318 hospitals surveyed by AHIMA had a CDI program in place. If all surveyed...

• Q&A: Respiratory failure in a drug overdose

  Q: I am looking for documentation or physician education tips related to ventilator management or...

• Local Chapter Update: Membership rosters due today

  A reminder to local chapter leaders to complete the ACDIS Local Chapter Agreement...

• Conference Update: Just over 50 days away!

  Can you believe that the 2016 ACDIS Conference is just over 50 days away? There’s...

Issue 12, March 24, 2016

• A Note from the Instructors: Transitioning to the CDI role

  By Sharme Brodie, RN, CCDS Usually the attendees in the basic CDI Boot Camp are brand new to the...

• News: Comments on C&M code proposals due April 8

  After a five-year code freeze, the ICD-10 classification system will be back on a regular cycle for...

• News: ICD-10 productivity survey respondents share challenges, successes

  In general, the time spent reviewing and coding records has increased since ICD-10 implementation...

• Q&A: Sequencing for influenza, pneumonia, and asthma

  Q: I am never sure of correct sequencing when the admission is for flu, pneumonia, and...

• Local Chapter Update: Upcoming meetings and events

  A reminder to local chapter leaders to complete the ACDIS Local Chapter Agreement...

• Conference Update: The countdown continues

  We’re less than 60 days away from the 2016 ACDIS Conference. The early bird registration...

Issue 11, March 17, 2016

• A Note from the CCDS Coordinator: New CCDS exam eligibility requirements take effect June 1

  by Penny Richards ACDIS announces several changes in eligibility requirements for candidates...

• News: CMS announces results from implementation of value-based payment modifier and adjustment factor

  Physicians in 128 groups exceeded benchmarks in quality and cost efficiency and will receive an...

• News: HHS reaches goal of tying 30 percent of Medicare payments to quality

  An estimated 30% of Medicare payments are now tied to alternative payment models that reward the...

• News: Inpatient coding errors top reason for hospital complex claim denials

  According to the American Hospital Association’s (AHA) 2015 fourth...

• Q&A: Present on admission conditions

  Q: Is a diagnosed and treated condition during the first 24 hours considered present on...

• Local Chapter Update: Spring meetings set; leaders to submit agreement forms and updated rosters

  Local chapter membership rosters will be due by the end of the month. Please remind local chapter...

• Conference Update: Early bird registration ends next Tuesday!

  Did you know that there are just over 60 days until the annual ACDIS conference? As you plan your...

Issue 10, March 10, 2016

• A Note from the Instructors: Hiring new CDI staff

  By Laurie Prescott, RN- MSN, CCDS, CDIP I am often asked by CDI managers and directors about how...

• News: Scenarios, input sought for CDI ethics panel discussion

  Members of the ACDIS Advisory Board will conduct a one-hour “CDI Ethics” panel...

• News: Partnership for Health IT Patient Safety releases copy and paste toolkit

  One of the biggest concerns regarding electronic health record implementation has been the...

• News: AHA urges government to reject further site-neutral payment policies

  Section 603 of the Bipartisan Budget Act of 2015 declared that any off-campus hospital...

• Q&A: Pressure sores present on admission

  Q: We are having trouble determining how to assign a code for a pressure ulcer that begins as...

• CCDS Update: Important news about the CCDS exam

  CCDS exam results for those who took the exam since January 18 will be issued at the end of March...

• Local Chapter Update: Upcoming meetings and events

  Reminder that all ACDIS chapter leaders should review and sign the official agreement...

• Conference Update: A few reminders; speaker Q&A

  The countdown clock to the ACDIS conference officially clicked over to just 74 days. But time runs...

Issue 9, March 3, 2016

• A Note from the ACDIS Editor: Consider contributing to our publications

  By: Katy Rushlau, ACDIS Editor Community. That’s what I think of when I think of the...

• News: International task force releases new sepsis definition

  The Third International Consensus Definitions Task Force updated the standards of sepsis and septic...

• News: An introduction to the 'Comprehensive Care for Joint Replacement' payment model

  Approximately 800 hospitals across the country that perform inpatient total hip and knee joint...

• News: Critical action needed for critical access hospitals

  Nearly 700 rural hospitals are at risk of closure, according to a report from iVantage...

• Q&A: Creating compliant verbal query processes

  Q: Can you clarify the expectations related to documenting the discussion between a physician...

• Local Chapter Update: Chapter leadership agreement forms due March 15

  The Chapter Advisory Board recently revised its local chapter agreement form to include...

• Conference Update: Think outside of the box

  We’re officially 80 days until the annual ACDIS Conference. As you begin to plan your...

Issue 8, February 25, 2016

• A Note from the Associate Director: Quarterly Conference Call highlights new ICD-10-PCS concerns

  More than 700 ACDIS members registered to participate in last week’s ACDIS Quarterly...

• News: CMS, AHIP Standardize Quality Measures

  CMS and representatives of the private insurance industry have agreed to use a single set of...

• News: AHRQ includes information on inpatient stays in Fast Facts

  Looking for more data on inpatient stays? The Agency for Healthcare Quality (AHRQ) added...

• Local Chapter Update: Local Chapter Update: Get involved, we are!

  Those of you who regularly attend your state events, consider volunteering to help leaders either...

• Conference Update: CDI and Quality

  We’re officially less than 100 days until the annual ACDIS Conference. As you begin to plan...

Issue 7, February 18, 2016

• A Note from the CCDS Coordinator:

  Do you hold the CCDS certification? Do you know when it expires? Once again, I heard from...

• News: CMS issues final rule for reporting, repaying Medicare overpayment

  CMS issued a final rule on February 11, 2016, creating a reporting and repayment...

• News: Appeals court ruling requires government to act on ALJ backlog

  The government will have to comply with its congressionally mandated deadlines for reviewing claims...

• News: Certain EHR features associated with fewer adverse events in some patients, report says

  Some patients being cared for in a fully electronic health record (EHR) environment were less...

• Q&A: Congestive heart failure coding

  Q: In the past few weeks, we noticed physicians are documenting acute congestive heart...

• Local Chapter Update: Upcoming meetings and events

  Here's what's coming up for our local chapters. 

• Conference: Behind the scenes at the ACDIS Conference

  We’re officially less than 100 days until the annual ACDIS Conference. The ACDIS office...

Issue 6, February 11, 2016

• A Note from the Associate Director: Preparing for new products

  It’s been an exciting and illuminating month since I became the associate director for...

• Conference Update: Discover best practices for CDI teams

  It’s that time of year again—the time when we start to count down to the 2016...

• News: CMS proposed rules to expand access to data, analyses

  Use of claims data could soon expand to a host of new entities under proposed rules...

• News: OIG continues Kwashiorkor targets

  Even though Promise Hospital of Ascension, a 54-bed transitional care hospital located in Gonzales...

• News: Latest AHA Recovery Auditor survey shows losses on outpatient and inpatient services

  Outpatient coding and billing errors led to more than half of all automated denials by Recovery...

• Local Chapter Update: Virginia, Illinois seek chapter leaders

  As local chapters begin 2016 meeting planning, many need your help. Specifically, Florida...

Issue 5, February 4, 2016

• A Note from the ACDIS Director: Nominate a colleague for the ACDIS Achievement Awards

  As you probably saw in last week’s CDI Strategies, we just welcomed four new ACDIS Advisory...

• CCDS Update: Take the CCDS Exam at the ACDIS Conference in Atlanta

  Those wishing to obtain their CCDS certification now have an opportunity to take the exam at the...

• Conference Update: Check out this year's pre-conference sessions

  Each year prior to the ACDIS Annual Conference, the event starts a few days early for those...

• Local Chapter Update: Plan ahead to attend nearby educational events

  Local ACDIS chapters provide a vital networking and educational service to clinical documentation...

• Feature: Skating toward the future of CDI

  Click here to read this article. 

• News: Survey reveals only minor productivity declines post ICD-10 implementation

  Productivity decreases post-ICD-10 implementation has been a major concern for CDI specialists...

• Product Spotlight: CDI for the Clinician

  Provide clinicians with what they need and want for CDI education. CDI for the Clinician...

• Job Highlight: Avera McKennan Hospital seeks physician advisor

  Click here to view the postings on the ACDIS job board. 

• Q&A: Clinically defining atrial fibrillation

  Q: Our facility is developing clinical definitions regarding types of atrial fibrillation...

• Poll: Does your CDI program have an outpatient review component?

  Click here to view poll results. 

• Survey: Share your thoughts on ICD-10 productivity and you could win a free HCPro webcast!

  ACDIS’s parent company, HCPro, is conducting its benchmarking survey on ICD-10 productivity...

Issue 4, January 28, 2016

• A Note from the Instructors: Connecting with coworkers

  As many of you know, working remotely has its advantages: the commute to work is easy, you can...

• Conference Update: Poster session application deadline extended

  ACDIS has extended the application deadline for poster session presentations to January 29...

• Local Chapter Update: Network with CDI specialists in your area

  Local ACDIS chapters provide a vital networking and educational service to clinical documentation...

• Feature: Improving the collaboration between CDI and case management

  Clinical documentation improvement (CDI) specialists and case managers share a common goal but...

• News: CMS underpays Medicare Advantage plans for treating chronic conditions

  CMS underpaid Medicare Advantage plans for the cost of treating patients with multiple chronic...

• Product Spotlight: The Physician Advisor’s Role in CDI Boot Camp

  With the transition to ICD-10-CM/PCS and the implementation of the Patient Protection and...

• Job Highlight: Massachusetts hospital seeks CDI Program Director

  Steward Health Care in Westwood, Massachusetts seeks a CDI program director, who will be...

• Q&A: How can we ensure the right documentation for a level of care recommendation?

  Q: As part of an integrated access management program, what medical documents are needed to...

Issue 3, January 21, 2016

• A Note from the CCDS Coordinator: What you need to know about the new CCDS Exam

  Record numbers of people took the CCDS exam in December and early January before the new version of...

• Membership Update: Congratulations to our new Advisory Board members

  ACDIS is delighted to announce the addition of four new Advisory Board members. The association...

• Conference Update: Time to submit your nominations for the ACDIS Achievement Awards

  It's time to submit your nominations for the ACDIS Achievement Awards, to be awarded at the...

• Local Chapter Update: Consider volunteering to help your networking group grow

  Local ACDIS chapters provide a vital networking and educational service to clinical documentation...

• Product Spotlight: The Complete Guide to CDI Management

  Managing a CDI department can be a daunting task. The Complete Guide to CDI...

• Job Highlight: Virginia hospital seeks clinical documentation integrity director

  Riverside Health System in Newport News, Virginia seeks a fulltime Clinical Documentation Integrity...

• Q&A: Query for "Type 2 injury"

  Q: I was reviewing a case with one of our CDI specialists this morning. Briefly, the following...

• Physician engagement in three ?easy? steps

  It’s an age-old question: How do you get physicians to support documentation improvement...

Issue 2, January 14, 2016

• A Note from the ACDIS Editor: A year in CDI

  It’s hard to believe that it’s been one year since I began my first day at ACDIS on...

• Membership Update: CDI Salary Survey released

  CDI salaries increased dramatically in 2015, according to nearly 800 respondents to the recently...

• Conference Update: Tips to convince your program to send you to the ACDIS conference

  Have you pitched attending the 2016 ACDIS conference in Atlanta to your boss yet...

• Local Chapter Update: Chapters seek volunteer leadership to assist with meeting facilitation

  Local ACDIS chapters provide a vital networking and educational service to clinical documentation...

• News: Time to submit your nominations for the ACDIS Achievement Awards

  ACDIS has made some significant changes to our annual ACDIS Achievement Awards, to be awarded...

• News: 2014 PQRS data available to public

  CMS recently expanded the amount of data available on its Physician Compare tool, to...

• News: CMS invites comments on 2-midnight rule payment calculation

  CMS has to explain its calculation for a negative 0.2% reduction in inpatient payment rates as a...

• Product Spotlight: Understand and Identify Patient Safety Indicator Targets

  Join speakers Mark LeBlanc, RN, MBA, CCDS and Michelle McCormack, RN, BSN, CCDS, CRCR on Tuesday...

• Job Highlight: Samaritan Health Services seeks regional ops manager

  Samaritan Health Services in Corvallis, Oregon seeks a regional operations manager to oversee...

Issue 1, January 7, 2016

• Associate Director's Note: CDI Strategies is going weekly!

  Welcome to the 2016th year of the Common Era (CE) and Anno Domini (AD) designations. The 16th year...

• Membership Update: New CDI Journal published

  We’ve made it to the New Year, which, for many, marks a fresh start. But as we put together...

• Certification Update: Meet our 3,000th CCDS holder

  ACDIS is proud to celebrate the 3,000th Certified Clinical Documentation Specialist (CCDS...

• Local Chapter Update: Chapter agreement forms, membership rosters, due soon

  With more than 40 local chapters and networking groups across the country there’s lots of...

• News: Voting now open for ACDIS advisory board--make your selections now!

  Voting is now open for four ACDIS advisory board positions, for terms of service starting in 2016...

• News: OIG sites Nebraska hospital for billing errors

  For calendar years (CYs) 2012 and 2013, Medicare overpaid Nebraska Methodist Hospital in Omaha more...

• News: Recently published Coding Clinic confirms some ICD-9 guidance still applicable

  The new AHA Coding Clinic for ICD-10-CM and ICD-10-PCS cleared up some confusion...

• Product Spotlight: The new CCDS Exam Study Guide is here

  In 2016, those sitting for the Certified Clinical Documentation Specialist (CCDS) exam face the...

• Job Highlight: Ohio hospital seeks CDI specialist

  The Christ Hospital Health Network in Cincinnati, Ohio seeks a fulltime CDI specialist to ensure...

• Q&A: Seeing oliguric and non-oliguric renal failure in documentation

  Q: I have seen documentation of oliguric renal failure and non-oliguric renal failure. What is...