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News: CDI Journal offers ICD-10 insight

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

A quick Q&A about CCDS recertification

Changes took place.

Everything you need to know about how to recertify.

Q: How far in advance can I renew my CCDS certification?

A: Please submit no more than 60 days prior to expire date. Your expiration date is every two years from the date you took the exam. That date is on your certificate and on the score sheet you received when you took the exam.

Q: What do you recommend as the best way to submit my recertification?

A: Complete and submit the application that is available on the ACIDS web site.

Q: I don’t see a way to do it online but do see a fax number.

A: There is no online application option offered.

Q: Do you recommend faxing the form, e-mailing it to you, or putting it in the mail?

A: Return it in whatever way you wish. Instructions are on the form.

Q: Is it ok to submit more than the required 30 or should I just stop once I reach 30 hours.

A: You only need to submit 30 hours. All CEUs must have been earned in the time you held the certification. Remaining CEUs cannot be used for a future recert. Note the restrictions outline on the form (not more than 10 CEUs for any single event other than certain HCPro-sponsored programs).

Need more information? Visit the recertification page on the ACDIS web site or email CCDS Exam Coordinator Penny Richards.

TBT: Lay the groundwork for peer audits

Broaden the scope of your CDI efforts by looking for medical necessity indicators and increasing proactive efforts to protect the record against audit risks.

The value of peer-to-peer review comes from the ability of CDI staff members to learn from each other.”Fran Jurcak, RN, MSN, CCDS,

Editor’s Note: In social media memes, Throw-back Thursday generally means sharing an old high school photo, something you likely wish had been left unpublished. Alternatively, we’ve flipped the theme around, going back into our archives to highlight some salient tid-bit worthy of second look. This week, we looked at an article from the January 2013 CDI Journal, Conduct peer audits to provide query practice insight.”

Before you develop a peer review process, establish policies and procedures for how and when to query. These policies should be clearly communicated to the CDI staff and reviewed annually to appropriately reflect changes in industry guidance. Because query policies and procedures define standards for the query process, they serve as a generally accepted common ground, says Donald Butler, RN, BSN, CDI program manager at Vidant Medical Center in Greenville, N.C.

Use those policies as a starting point for your audit processes, Butler says. The audit forms and actions need not repeat facility policy language verbatim, but they can and should refer to facility-specific documents and original industry recommendations, he says.

Without this source material guiding the peer audit process, CDI staff members may question its legitimacy.

Ensuring that CDI specialists support the audit process is the second step, says Donna Kent, RN, BSN, CCDS, CDI manager at Torrance (Calif.) Memorial Medical Center. Kent remembers performing peer reviews as a nurse in the hospital. When she made the move to CDI, she lamented the lack of such audits. For some time Kent’s staff was too small to make the peer audit process successful.

“All of us, at one time or another, have experienced reviews that were punitive just for the sake of being punitive,” says Kent. “For peer-to-peer audits to be successful, they must be used as a learning and evaluation tool, not as some sort of gotcha game.”

“The value of peer-to-peer review comes from the ability of CDI staff members to learn from each other, to see what each other is doing and support process improvement,” says Fran Jurcak, RN, MSN, CCDS, CDI director at Huron Healthcare Consulting Group in Chicago.

Each person has his or her own style, strengths, and foibles, says Kent.

For example, in reviewing a record regarding excisional debridement, one CDI specialist may read the record and see no query opportunities. Another CDI specialist may remember a Coding Clinic reference regarding excisional debridement and determine a query opportunity does exist.

There may not be a right or wrong to this scenario, Kent says. Instead, there is an opportunity for the two staff members to discuss their views and the various options open to them during the query process. Through that dialogue, she says, comes learning.

Sunday Reading: Injuries in ICD-10  

The CDI Specialist's Guide to ICD-10

The CDI Specialist’s Guide to ICD-10

The Official Guidelines for Coding and Reporting state that “traumatic injury codes (S00-T14.9) are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds.” The tabular list note at the beginning of the Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88) tells coders to “use secondary code(s) from Chapter 20, External Causes of Morbidity, to indicate cause of injury.”

Codes within the T section that include the external cause do not require an additional external cause code. In this group, S codes describe various types of injuries related to a single body region, and T codes describe injuries associated with unspecified body regions as well as poisonings and certain other consequences of external causes. Although CDI specialists have not typically queried for external cause codes (E codes in ICD-9-CM and V00-Y99 codes in ICD-10-CM), these combination codes will require additional documentation from the provider detailing the events surrounding the injury once the new code set implementation takes place.

Regarding the circumstances of the injury, when no intent is indicated, the default is accidental. The Official Guidelines for Coding and Reporting I.C.20.h.1 states that “if the intent (accident, self-harm, assault) of the cause of an injury or other condition is unknown or unspecified, code the intent as accidental intent.” Although the available codes include “events of undetermined intent,” they should be used only if the physician specifically documents that the intent cannot be determined.

In ICD-10-CM, injuries are grouped by body part rather than by category. The organization aligns with how providers document injuries—often a systematic progression from head to toe after the most serious injury is assessed. The focus of treatment can be misleading to those without a clinical background or expertise coding traumatic injuries. For example, a patient may be in the intensive care unit for a neurological injury that requires a high level of nursing care and repeat imaging, but if the coder does not review the nursing notes and imaging reports, all he or she may notice is that an open fracture of a limb was treated with required antibiotics and surgical care.

Although the grouping changed, Official Guidelines for Coding and Reporting are similar, calling for separate codes for each injury unless a combination code is required. Remember that a code can only ever be reported once, so duplicate codes should never appear on a claim. Also, use of a combination code may require a query if the documentation does not already support use of the particular combination code. Figure 5.10 illustrates some of the changes in the injury code set.

Codes organized by type of injury and then by site:


  • Fractures (800–829); e.g., skull, upper limb
  • Dislocations (830–839)
  • Sprains and strains (840–848)
  • Intracranial injury (850–854)
  • Internal injury (860–869)
  • Open wounds (870–897)


Codes organized by site and then by type of injury:


Example: Injuries to head (S00–S09)

  • Superficial
  • Contusions
  • Open wounds
  • Fracture
  • Dislocation, etc.


Editor’s Note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Guide to ICD-10, Second Edition, written by HCPro Boot Camp instructors Jennifer Avery and Cheryl Ericson.

ICD-10 Tip of the Week: Implementation Guidance from CMS

ICD-10 implementation is not game. Tell your elected officials to stop playing around with the implementation date.

ICD-10 implementation is not game. There’s no room for playing around.

With less than 30 days to go until ICD-10-CM/PCS implementation, there’s no shortage of last minute assistance and advice being aired. Perhaps, however, the best ICD-10 education can be found completely for free.

If you haven’t already done so, download the Official Guidelines for Coding and Reporting from either CMS or the CDC. You can also download the actual codes and indexes, and the ICD-10-PCS Reference Manual.

On August 27, CMS hosted its MLN Connects Call featuring CMS Acting Administrator Andy Slavitt, Sue Bowman from the American Health Information Management Association (AHIMA) and Nelly Leon-Chisen from the American Hospital Association (AHA) who each offered coding guidance, tips, and updates from CMS.

Following the deal that CMS struck with the American Medical Association regarding ICD-10-CM/PCS implementation, the agency also released several guidance documents regarding the use of unspecified codes after the go-live date including:

CMS also launched an ICD-10 Clinical Concepts Series for Specialties to help physicians and other providers get up to speed for family practice, internal medicine, cardiology, OB/GYN, orthopedics, and even pediatrics. Each guide compiles key information from the Road to 10 online tool in a PDF format that can be readily shared, emailed, posted to websites, and printed. The guides include common ICD-10 codes, clinical documentation tips, clinical scenarios, and links to interactive cases studies, in-depth webinars, and other Road to 10 features.

Visit the ICD-10 Medicare Fee-For-Service Provider Resources web page for a complete list of Medicare Learning Network educational materials.

TBT: Throwback pricing on the 2015 Medicare Compliance Forum


The Medicare Compliance Forum will be held Oct. 26-28.

The countdown is on! The 2015 Medicare Compliance Forum is right around the corner on October 27–28, in beautiful Charleston, South Carolina. We hope you’ll join us for the latest information and updates on Medicare rules and regulations.

If you’re thinking of registering but haven’t done so, for the next 48 hours only we are offering a special discount—we’re throwing it back to our early bird rates, which will save you $100 on registration! Just use discount code ET325075. For more information, click here.

The Medicare Compliance Forum will offer six session tracks over two days, including one track dedicated to CDI. Sessions for CDI specialists include:

  • Leveraging CDI Specialists to Enhance Utilization Review
  • Document, Document, Document: Enhance Documentation to Drive Meaningful Data
  • Is Your Readmission Problem Really a Documentation Problem?
  • CDI and the Quality Mandate
  • The Role of CDI and the EHR in Supporting Medical Necessity

CDI session speakers include Deborah K. Hale, CCS, CCDS, John Zelem, MD, FACS, and Cheryl Ericson, MS, RN, CCDS, CDIP.

Ericson, the CDI Program Manager for ezDi and ACDIS Advisory Board member, spoke with HCPro about the CDI track, and the issues she hopes to address in her sessions, including medical necessity, the 2-midnight rule, and physician documentation. She also discusses the beautiful city of Charleston and all it has to offer for visitors. Click here to listen.

“I’ve been working in the CDI industry for several years now and we’re seeing that Medicare is making policies that really encourage organizations to be collaborative in their approach through the revenue cycle,” says Ericson. “I’m going to be talking about the ways CDI can be integrated into some of the practices that you already have.”

Ericson is also presenting a CDI-related pre-ference on October 26.

Meet Nancy Shows: ACDIS’ New CDI Education Specialist


Nancy Shows, B.S., RN, CCM, CCDS

Clinical documentation is the perfect practice area for me at this point in my career, because I utilize all of my past professional knowledge and experience on a daily basis. I am proud to be working in an area where the ultimate goal is achieving the highest quality documentation in each patient’s medical record when they access the healthcare system. Since I also love to teach, when I saw the job posting on the ACDIS website for a CDI Education Specialist and heard Brian Murphy encourage people to apply on the ACDIS Radio Show, I applied for the position.

I started down my healthcare career path back in late 1970s when I attended Michigan State University and earned a B.S. in dietetics. I was accepted into the Coordinated Undergraduate Program, completed clinical dietetics and foodservice management internships, and was able to take the registered dietitian (RD) exam shortly after graduation. I worked as a RD in a variety of healthcare settings, including hospitals (clinical and teaching positions), health departments (WIC, Maternal Support Services, Infant Support Services), and consulting firms. While working as a RD on teams with registered nurses, I began to see the narrow scope of working as a nutrition professional compared to the much wider scope of a nursing professional. I learned I wanted to help people in more areas of their lives than nutrition.

So, I decided to go back to school at Lansing Community College’s nursing program on an academic scholarship and graduated top of my class. Partly due to my extensive work with moms and babies as a dietitian, I then got a job in a Level 3 neonatal intensive care unit (NICU) at Henry Ford Hospital in Detroit. I have so many special memories from that experience.

In the ensuing years, I held various positions in healthcare, including management, case management (have been a certified case manager since 2010), utilization management, patient access, pharmacovigilance, subacute rehab/skilled nursing, consulting, and quality/core measures. I began working as a clinical documentation specialist (CDS) in January, 2011, back “home” at Henry Ford Hospital. Since then, I have worked at another large health system, the Detroit Medical Center, as a CDI specialist and have worked as a consulting CDI specialist for MedPartners. Satellite pictures I became a certified clinical documentation specialist (CCDS) in January 2013.

I never dreamed that I would be selected, but sometimes dreams do come true! I am so grateful for this amazing opportunity, for being part of this awesome CDI team, and I look forward to sharing my passion for clinical documentation with HCPro Boot Camp attendees across the country.


There are several people I have to thank for helping me get to this place in my career:

  • My mom, Margaret—my number one fan.
  • My daughter, Lynn, and my son, Ray, who were ages 7 and 5, respectively, when I returned to school to become a nurse. They’ve always been my cheerleaders.
  • My husband, Felix, who said, “Go for it!” and “It’s YOUR time now” when I asked him what he thought about me applying for this position.
  • My sister, Kate Upton, who has worked in healthcare as an administrator/executive for three decades, for listening and offering her highly intelligent, knowledgeable support and encouragement.
  • My former managers and lifelong mentors, Dana Murphy and Patti Nemeth, and former coworker, Rita Ferrell, who dropped everything at a moment’s notice to discuss this wonderful opportunity and for encouraging me.

- Nancy Shows, B.S., RN, CCM, CCDS

Q&A: PCS coding for perineal laceration

Have a question that is troubling you and your team? Ask us!

Have a question that is troubling you and your team? Ask us!

Q: I am having trouble with the procedure (PCS) coding for a perineal laceration repair. Some sources state that the correct code uses the perineal anatomic region, not muscle repair. Would you please clarify the correct ICD-10-PCS code for a second degree obstetrical (perineum) laceration that includes muscle?

A: This is a challenging area of ICD-10-PCS coding. Repair of obstetric lacerations documentation can often lead to miscoding, so we need to clearly document perineal lacerations and related treatments.

There is conflicting guidance online regarding this procedure, but the Coding Clinic, Fourth Quarter 2013, p. 120 does provide a definitive example to clarify appropriate code assignment. It discusses the case of a 25-year-old patient who had a normal spontaneous vaginal delivery at 39 weeks gestation and suffered a second degree perineum laceration. The repair involved suturing of the muscle.

In this instance, Coding Clinic says to assign code 0KQM0ZZ, repair perineum muscle, open approach. In ICD-10-PCS, an “open” approach is defined as cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure. In this case, “open approach” is assigned because the laceration has cut through the external body layers, exposing the muscle (i.e. site of the procedure).

Although the laceration occurred spontaneously, it is nevertheless the means by which the procedure site is exposed. The same principle would apply for a laceration repair caused by other means, such as a knife wound that lacerates the liver.

Editor’s Note: Mark Morsch, MS, AHIMA-Approved ICD-10-CM/PCS Trainer, vice president of technology for Optum360, and Tom Darr, MD, chief medical officer for Optum360, answered this question. To access their free webcast, “Beyond the Planning: Post-Implementation Strategies for CDI and ICD-10,” presented by Optum360 and hosted by ACDIS, click here.

Q&A: Physician advisor collaboration with CDI


Thomas W. Huth, MD, MBA, FACP,

Editor’s Note: As part of the fifth annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Thomas W. Huth, MD, MBA, FACP, Vice President of Medical Affairs at Reid Hospital & Health Care Services in Richmond, Indiana, answered the following questions regarding physician advisor’s role in CDI. With more than 20 years of clinical practice experience and a Master of Business Administration degree, Huth has served in a variety of medical staff, organized medicine, and community leadership roles. Contact him at

Q: Can you describe your role as a physician advisor to CDI?

A: I give expert guidance to the CDI specialists when they have questions about what to query, and how to do it, and how to approach the doctors in an effective manner.

Q: Can you describe the engagement and collaboration of your medical staff in CDI?

A: We work to establish a cultural expectation of engagement and collaboration of the medical staff with the CDI specialists. We provide constant feedback to the doctors and to the medical staff leaders about performance. We also ask the medical staff leaders to send the message to the individual doctors about the importance of CDI to the quality of care for patients and the objective performance of the organization on severity adjusted metrics.


Q: What has been your most successful approach for obtaining physician buy-in?

A: We have had good success by providing physician-specific feedback on the impact of complete and thorough documentation to measures of quality and efficiency. When doctors are shown their own data they usually become much more engaged in the process.


Q: Does your medical executive committee have an escalation policy or other policy requiring physicians to respond to queries/CDI clarifications in a set timeframe? Can you describe its effectiveness?

A: We have an analytics team which gathers in-depth data on physician response rates and we provide that to doctors on a weekly basis. Consequently, our response rates have improved to above 90% in most weeks. There is a comparable rate of agreement with the CDI specialist’s assessment. We don’t emphasize agreement rates to the doctors and we don’t report the rates to them individually. Instead, we use agreement rates as a measure of the quality and appropriateness of the CDI specialists’ queries.


Q: What are your biggest challenges with getting physician buy-in?

A: Keeping doctors engaged in improving the processes and quality of documentation since they have a lot of other priorities.


Q: What do you think the role of the CDI physician advisor is/should be in terms of program advancement and analysis?

A:  It’s very important to have a physician advisor with advanced training in CDI available to the CDI team. The advisor should be an effective liaison to, and teacher of, the medical staff. The physician advisor can provide many useful insights into the data and help plan improvement projects.

Q&A: The Role of the Physician Advisor in CDI


Rebecca Hernandez, RN, BSN


Zachary Fainman, MD

 Editor’s Note: As part of the fifth annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Zachary Fainman, MD, co-medical director and physician advisor of care management at Advocate Luther an General Hospital in Park Ridge, Illinois, offered his insight into the role of the physician advisor in CDI. Fainman provides oversight over care management, social work, utilization management, government audit and CDI, a position he has held since 2011. Fainman is also the founder of the physician advisor committee at Advocate System. Contact him at Rebecca Hernandez, RN, BSN, CDI program supervisor works with and educates CDI specialists, nurses, physicians, and other healthcare practitioners to ensure accuracy and timely clinical documentation in the medical record. Contact her at

Q: Can you describe your role as a physician advisor to CDI?

A: As physician advisor to CDI, I act as an interface with physicians and CDI specialists. I also give my input on issues where CDI and coding may approach clinical situations from different perspectives.

I work hand in hand with Rebecca Hernandez, our CDI supervisor, in reviewing CDI department and physician metrics, and troubleshooting physician/CDI dynamics. In addition, Rebecca and I provide individualized physician education using their real time clinical cases and translating the case into quality data metrics to explain why CDI is critical to their practices as well as to the institution.

Q: Can you describe the engagement and collaboration of your medical staff in CDI?

A: The issues of trust, respect, and credibility are paramount in achieving engagement and collaboration.  My 20-plus years of clinical experience, as well as my knowledge of regulatory requirements from both governmental and private payors, has been helpful in gaining credibility.

Rebecca’s experience as a critical care nurse, as well as her exposure to multiple healthcare systems as a travel nurse, has gained her respect along with credibility. Thanks to the hard work of our CDI specialists, coders, and leadership, I believe our medical staff is extremely well engaged and collaborative.

Q: What has been your most successful approach for obtaining physician buy-in?

A: I sincerely believe our most successful approach has been individualized and data-driven education.  Rebecca, in collaboration with our medical directors and coding manager, has put together succinct straightforward clinical case studies which provide a clear and relevant picture of how CDI impacts not only revenue, but quality metrics as well.

As in any CDI program, one of the challenges is to get the physician to attend an educational meeting to gain buy-in. One way we get physicians to attend is by respecting their time constraints. So, we remain flexible with our meeting times and venues. Once we get the physicians to attend, they are grateful for the explanation and will actually seek out CDI specialists for their input.

Q: Does your medical executive committee have an escalation policy or other policy requiring physicians to respond to queries/CDI clarification in a set time?  Can you describe its effectiveness?

A: Yes, queries are expected to be answered within 24 hours. If not, the physician receives follow up communication (method of their choosing) from CDI specialists. If there is still no response, within an additional 24 hours, the physician advisor will contact physician and he is unable to obtain response, will escalate the situation to the chief medical officer. So far, this process has been very effective. With a medical staff of about 1,400 physicians, only a few have been escalated to the chief medical officer level.

Q:  What are your biggest challenges with getting physician buy-in?

A: Again, trust is a big issue. At first, physicians believe only the institution will benefit from CDI by realizing an increase in revenue. Once the CDI/physician advisor staff establishes credibility with the medical staff, this issue is abated.

Fear of litigation or government audit is also a barrier. Once the physician is convinced that accurate documentation may in fact positively impact these issues, these barriers are also mitigated. Physicians must be shown that staff and leadership of the institution really do care about them and demonstrating that CDI can aid in presenting an accurate picture of physician performance is one way to prove this.

Q: What do you think the role of the CDI physician advisor is/should be in terms of program advancement and analysis?

A: This again is a dual role between physician advisor and CDI leadership. Data must be available as to the impact on metrics such as length of stay, risk of mortality, severity of illness, case mix index, and complications among other measures. Also, this is a continuous process and does not involve a “one time” meeting. The accuracy of the data is crucial, if not accurate, credibility is at risk.