Health Information Management

Associate Director's Note: Happy ICD-10-CM/PCS implementation day!

CDI Strategies, October 1, 2015

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As I mentioned in the most recent edition of the CDI Journal, my 96-year-old grandmother recently took a spill. She hit her head on the corner of the kitchen counter, which earned her seven stitches over her left eye plus a compression fracture in her neck. Within 24 hours she obtained an infection—pneumonia. And then, she became delirious. She came around fairly quickly, thank goodness, and was back to her cheery self by the next day. (She happily stole my new hat and asked the nurses how she looked.)

Now, I am not a nurse. I’m not a coder either. But after 10 years at HCPro, eight of them as the Associate Director of ACDIS, I know enough to be dangerous, enough to ask the nurses to make sure my grandmother’s medical record clearly documented the type of pneumonia (and that it was not present on admission). I knew enough to ask them to be specific when describing the type of altered mental status she had, too.

As ICD-10-CM/PCS implementation takes place, CDI teams will need to work to obtain ever more specificity to capture the clinical picture of the patient’s treatment. Type, treatment, and causative organism for the pneumonia. Linking language such as “sepsis due to Foley catheter and urinary infection.” Laterality.

The good news for CDI specialists is that although the code set may be new, the concept of querying for greater specificity is not. All CDI specialists need to worry about is to keep doing the amazing work you do. If you need additional go-live advice, we’ve got it for you throughout the latest edition of CDI Journal.

If you haven’t seen the Sept./Oct. edition here’s a look at some of the articles you’ll find inside:

  •  Implementation Advice: Picking last-minute ICD-10-CM/PCS priorities
  • Last-minute ICD-10 training tips for documentation
  • Ask ACDIS: Non-treating physician responses to queries
  • In the News: CCDS certification set to receive an ICD-10 update
  • Meet a member: Foreign Medical Grad finds CDI home in California
  • Ask ACDIS: Escalation policies and clinical validation queries
  • Clinically Speaking: Adding venous thromboembolism to the CDI checklist
  • Coding Clinic for CDI: Defining root operations
  • Outpatient Efforts: One system's efforts to address physician practice documentation improvement needs

And we want to hear your go-live journey stories and tales of how your documentation improvement efforts helped improve patient care. Email them to me at

Good luck today!

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