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Weekend Reading: Specific guidelines for complications of care


The 2016 CDI Pocket Guide

Not all conditions that occur during or following medical care or surgery are complications. To properly code a condition as a complication of care, there must be:

An unexpected or unusual outcome is caused by the care rendered—not a routinely expected or common condition or occurrence.

For example, a significant amount of blood loss is usual and expected with joint replacement surgery. Therefore, hemorrhage would not be coded or considered a complication of care unless such bleeding was particularly excessive or unexpected and documented as such.

An established cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that condition was a complication.

Do not assume a cause-and-effect relationship exists. To be most specific, physicians should state that a particular condition is “due to” or “resulted from” or “is the result of ” a procedure or the care provided to identify it as a complication of care.

Exception: For obstetric patients, the provider must specifically state that a condition is NOT affecting a pregnancy or it is assumed to be so.

Don’t become encoder-dependent. Terminology in the Alphabetic Index or Tabular List of the ICD-10-CM code set can often provide insight or guidance, particularly for complications of care. Also check Includes and Excludes notes carefully.

With ICD-10, intraoperative and postprocedural complication codes are found within the body system chapter with codes specific to the organs and structures of that body system. These codes should be sequenced first, followed by a code(s) for the specific complication, if applicable, according to the Official Guidelines for Coding and Reporting. ICD-10 has greatly expanded complication of care codes that include:

  • Specific intraoperative and postprocedural complications for each body system (e.g., nervous, circulatory, respiratory, digestive, genitourinary)
  • Transplanted organs and tissues
  • Complications following infusions, transfusion and therapeutic injections
  • Prosthetic devices, implants and grafts
  • Procedures, not elsewhere classified (e.g., postprocedural shock, postprocedural infection, wound dehiscence)

While most of these conditions are listed under a category titled “complication,” in many cases, the causal relationship is implicit in the condition. In these instances, it would not be necessary for the provider to document the relationship between the condition and the care or procedure. For example:

  • Hemorrhage during CABG surgery (I97.411)
  • Surgical wound infection following simple appendectomy (T81.4)
  • Leakage of cystostomy catheter (T83.030)
  • Wound dehiscence (T81.30XA)
  • Iatrogenic pneumothorax (J85.811)

Specific documentation of the term “iatrogenic” literally means “caused by a physician (i.e., medical care).”

Editor’s Note: This excerpt come from the 2016 CDI Pocket Guide by Richard D. Pinson, MD, CCS and Cynthia L. Tang, RHIA, CCS.

Gold’s Gospel: Arrested development

Dr. Robert S. Gold

Dr. Robert S. Gold

By, Robert S. Gold, MD

Although we have gone through years of confusion regarding “cardiac arrest” and probably came to some conclusions about when it gets coded and when it doesn’t, this Ghost of CDI Past has come back to haunt us.

The code for cardiac arrest in ICD-9-CM was 427.5. In ICD-10-CM, it has expanded to include elements of the I46 series, where I46.2 represents cardiac arrest due to an underlying cardiac condition, I46.8 represents cardiac arrest from some other underlying condition and I46.9 is for “I have no idea why” cardiac arrest (also known as cause unspecified).

Well, first things first (again): In the process of dying of some chronic or acute disease or traumatic process, the heart stops. No cardiac arrest code is applied for these circumstances at all.

On the other hand, if the patient is not expected to be in the process of dying and something happens and the heart stops, whether it’s called sudden cardiac death or cardiac arrest, then the cardiac arrest code is assigned.

If the cause is known, or pretty clear even if it’s not known, then the specific code is assigned. Cardiac arrest due to ventricular fibrillation gets the I46.2 code as well as the specific code for ventricular fibrillation (I49.01) for the added specificity.

When the cause is hypercalcemia or hyperkalemia, then we have the I46.8 code plus the specific code for the electrolyte disturbance that led to the cessation of heartbeat. OK, that’s one. We code it when it’s appropriate to code it.

But, as I have heard in ICD-9-CM and am now starting to hear in ICD-10-CM, “We’re giving CPR, which is ‘cardiopulmonary resuscitation,’ and the patient’s oxygen saturation is 60%, so obviously the patient has acute hypoxic respiratory failure, right?” Wrong!

When the heart stops, whether while dying from lung cancer or responding to a massive ST elevation myocardial infarction at the origin of the left anterior descending coronary artery, breathing stops, renal function stops, the brain function stops—the patient dies—unless circulation can be restored. So all this advice of getting doctors to document “acute hypoxic respiratory failure” just because the oxygen saturations are low is bogus.

Does this mean that the two can never be coded together? Not at all! If the acute hypoxemic event precedes the cardiac arrest, as in drowning or smoke inhalation or acute pulmonary edema, and that is followed by a fatal arrhythmia or a myocardial infarction which stops the heart suddenly, then it is quite proper to look at having both events documented and coded. But you don’t shoot for a diagnosis just because of a lab result and your opinion that “it just makes sense.”

Editor’s Note: This post was originally published in Just Coding.

Membership Update: Attend the ACDIS Quarterly Conference Call

Join us this for these free audioconference/webinars

Members, please join us for our quarterly conference call.

The first quarterly conference call for 2016 will be held Thursday, February 18, and all members are invited to attend.

ACDIS quarterly conference calls are a one-hour, live telephone conference call, featuring discussions on emerging topics, open networking discussions, and a question and answer period with the ACDIS Advisory Board. More than 600 ACDIS members joined the discussion during our last quarterly call in November. We hope you’ll join us.

The agenda includes:

  • Capturing appropriate risk adjustments for total documentation integrity
  • ICD-10 unspecified codes
  • Role of CDI professionals in EHR adoption
  • Comparison of onsite versus remote CDI staffing models
  • CDI reviews for risk-adjusted payment methods (outpatient CDI efforts)
  • Open Q&A

We want your ideas and questions! If you have a question to ask the ACDIS advisory board, or general suggestions for discussion on the upcoming call, please e-mail Melissa Varnavas at

ACDIS members receive dial-in instructions via e-mail. Members are encouraged to dial in at any time with their comments, thoughts, and questions, and may do so by pressing *1 on their telephone keypad. Call participants also have the opportunity to take a survey and obtain CCDS CEU credits by visiting the Quarterly Conference Call section of the ACDIS website

To learn more, and to listen to previous call recordings, click here.

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

ACDIS Director Brian Murphy

ACDIS Director Brian Murphy

Got a great colleague, or know of a terrific CDI peer? Nominate them for the ACDIS Achievement Awards! 

As you probably saw in last week’s CDI Strategies, we just welcomed four new ACDIS Advisory Board members into the fold. These folks do quite a bit of work that goes unnoticed. One of their achievements in the last quarter of 2015 was revising what had been our CDI Professional of the Year awards. Through their hard work we now have an expanded, more inclusive set of honors we are calling the ACDIS Achievement Awards.

In the past we honored one CDI Professional of the Year and two Recognition of CDI Professional Achievement winners. In 2016, the CDI Professional of the Year award will continue to represent our association’s highest honor. This individual demonstrates great accomplishments both in their facility and within the greater industry, through serving on an ACDIS board, committee, local chapter, or providing advice and mentoring to others within their community.

We will also honor one individual with Recognition of CDI Professional Achievement award. The successful nominee for this honor would be someone who has gone above and beyond to make a difference in their hospital.

We’ve also added two entirely new awards to acknowledge the incredible growth and expansion of the CDI profession.

The first is our Rookie of the Year award. This honor will recognize an outstanding newcomer who has been in the CDI profession no more than two years at the time of submission. CDI is an exploding profession and if you have a newcomer who has exceeded expectations and is on their way to CDI superstardom, nominate them!

The next is our Excellence in Provider Engagement award. One of the many great ways the CDI profession is expanding is the addition of physician advisors, who have greatly increased the buy-in of medical staffs. And we’re seeing some CDI departments allow reviewers to grow into educators, presenting in front of physician specialties or engaging in one-on-one mentoring. These are two great potential candidates for this award.

If you haven’t been to an ACDIS conference to see the type of recognition these folks receive, you’re missing out. They’ll be honored in front of 1,500 of their peers on Day 1 with a description of their achievements and a reward they’ll treasure forever. Our CDI Professional of the Year also gets to attendee the conference for free.

Some important industry names that you might recognize have taken home these awards, including Karen Newhouser, Don Butler, Nancy Ignatowitz, and others.

Of course your peers can’t win if you don’t nominate them. We’ve made it as easy as possible with an online form. Just fill out the fields, explaining why your candidate is a CDI rock star, attach any letters of recommendation or other supporting documentation, and send it off.

The deadline is Friday, February 5.

For more information or to get started with a nomination check out our awards page here:


Weekend Reading: Defining a mission


The Complete Guide to CDI Management

As you begin to think about what your own CDI department may look like, you will need to define your departmental mission. It can be useful to meet with managers of other revenue cycle departments to ensure a clear understanding of their roles within the organization. This will allow the CDI mission and workflow to complement other revenue cycle efforts and may enlist the support of these other departments.

The scope of CDI continues to expand as organizations identify documentation gaps that affect organizational processes, so the CDI manager is often expected to use his or her staff to address these issues. Examine what you hope to accomplish by initiating this effort. Make sure you clearly understand how the organization will measure its success, so you can determine how the CDI department can contribute to that effort. Ask the following questions:

  • Is the emphasis incremental revenue?
  • Is the goal to improve the profile of your facility regarding metrics that can represent the quality of care such as severity of illness (SOI) and risk of mortality (ROM)?
  • Is it truly to improve the quality of your providers’ overall documentation without regard to reimbursement or other factors?

The definition of success will vary based on the desires of your organization, but, as the manager, you must know your mission to guide your department towards its goal. The mission affects staffing, workflow, metrics, and other elements of the program that you need to consider.

Editor’s Note: This excerpt comes from the recently published book, The Complete Guide to CDI Management, by Cheryl Ericson, MS, RN, CCDS, CDIP, Stephanie Hawley, RN, BSN, ACM, and Anny Pang Yuen, RHIA, CCS, CCDS, CDIP.

Conference Update: Discover best practices for CDI teams

acdis_baseIt’s that time of year again—the time when we start to count down to the 2016 ACDIS conference by chatting about what’s new and exciting, and hearing from a few of our speakers about their sessions.

The conference takes place May 23-26, 2016 in Atlanta, Georgia, and features five tracks that includes:

  • Clinical and coding
  • Management and leadership
  • Quality and regulatory
  • CDI expansion
  • Innovative CDI

To view the full agenda and details, download the conference brochure.

This year, we are also offering three exciting pre-conferences. One of our new offerings is the two-day “Building a Best Practice CDI Team” program, presented by Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS, CDI specialists and authors of the authoritative, best-selling CDI Pocket Guide.

Pinson will also be speaking at our main conference, presenting, “The CDI Operational Road Map: Uniting Physician Champions, CDI Team, and Medical Staff.” Tang and Pinson discussed their sessions over e-mail, and collaborated on their responses about what they’re looking forward to about this years’ conference.

Q: Why should managers send their CDI teams to your pre-conference session?

A: Our CDI Pocket Guide has become the authoritative, go-to resource for thousands of CDI specialists. In our two-day workshop for physician advisors and their CDI team members, we show you how to apply the principles embodied in the CDI Pocket Guide through best practice processes and key performance indicators that track improvement. We make clinical documentation easy to navigate, and we make it clear to all members of the healthcare team why CDI is so important for patients as well as the hospital. Our workshop is valuable whether your CDI program is well-established or just starting out, because participants learn new information and practices that they can implement for immediate results when they return home.

Q: What are some of the “highlights” attendees can expect from our session?

A: The focus of our workshop is “best practices” for the CDI team, but attendees will also get to expand and strengthen their knowledge of evidence-based clinical criteria for important diagnoses. In addition, during our program attendees will discover how to incorporate pay-for-performance and quality initiatives easily and effectively into their programs. Finally, they will get a common-sense approach to physician advisor participation and engaging medical staff. Participants will gain a more thorough understanding of the key diagnostic challenges that affect revenue and patient care, and simple but powerful techniques for evaluating and strengthening their CDI program.

Q: How is your topic important for everyone in the CDI role, regardless of professional background?

A: One of the challenges in developing a coherent CDI program is precisely that many hospitals have a hard time engaging all members of the healthcare team. Because our team includes both a physician and CDI specialist who each have decades of expertise under their belts, we are able to speak directly to each member of the CDI program, from coders to physicians.

Q: As a physician and an RHIA, how does your perspective differ from other CDI professionals?

A: Throughout our 12 years of collaborative work, we have always sought to combine clinical practice with coding principles conveyed in a simple language that puts coders, clinical documentation specialists, and physicians all “on the same page.”  Too often, one or more of these crucial stakeholders are left out.  We offer a rational framework for CDI based on our extensive training and experience, always supported by evidence.

Q: What do you think is the most important quality for a CDI professional to have?

A: Curiosity, a love for learning, and a confident approach to communicating with physicians.

Q: What are you most looking forward to about the 2016 ACDIS Conference?

A: A chance to show our new CDI products and tools offered in collaboration with ACDIS/HCPro, including our new mobile apps, and our innovative e-Learning solution for physicians: CDI for the Clinician ™.


Guest Post: Bridge the communication gap with physicians with these tips

Reach out to your physician advisors, case managers, chief medical officers, vice president of medical affairs, president of the medical staff, and any other supportive individuals in your facility.

Adopting a few simple strategies can help clear the paths of communication between CDI and physicians.

Do you sometimes feel like you and the physicians at your hospital aren’t communicating as well as you could be? Even the best of us can feel like a buzzing fly, annoying physicians when trying to gather needed information in the middle of a busy day, says James Haering, DO, SFHM, a physician and the vice president of appeals and physician services for Resonant Physician Advisory Services in Tacoma, Washington.

But it doesn’t have to be that way. Adopting the following simple strategies help clear the paths of communication:

  • Make sure physicians know who you are. It seems obvious, but make a point of ensuring all physicians know who [the CDI team is] are and how to reach them. “I can’t have a relationship [with you] if I don’t know who you are, where you are, or even how to get ahold of you,” says Haering. “Depending on the size of the hospital, you might literally want to put a photo of yourself on the unit with your name and contact information … This will be a great help if you have a doctor that is new or who only comes by occasionally.”
  • Hit the floor. If you spend most of your day cloistered away looking at electronic medical records, you’re missing a valuable opportunity. Relying too heavily on the electronic record likely means [CDI professionals] aren’t near the patient and aren’t near [physicians], Haering says. Face time is critical to ensuring the best possible communication between physicians and CDI professionals.
  • Speak carefully. Although CDI specialists pride themselves as good communicators, remember that coding terminology can be a foreign language for physicians. Phrase your requests carefully so it doesn’t appear that you are challenging the physician’s clinical judgement. . “Even accidentally making the doctor appear wrong, is a quick way to make them shut down and not work with you. you make the doctor look    says Haering.

By taking the right approach and making sure the physician knows you and can reach you easily, you’ll be much more likely to foster a relationship that is open and that can benefit the patient.

Editor’s Note: This article was originally published in the newsletter Case Management Monthly.

Tip Tuesday: Balance productivity and specificity

CDI is all about balance.

CDI is all about balance.

Productivity has been a huge concern for both CDI specialists and coders. With the added specify in ICD-10, facilities need to strike a balance between getting claims out the door and capturing the full clinical picture is key, says ACDIS Advisory Board member Judy Schade, RN, MSN, CCM, CCDS, CDI specialist at Mayo Clinic Hospital in Arizona.

In an effort to increase or maintain post-implementation productivity, some facilities let the smaller diagnoses and procedures, and query opportunities, go, says Schade. For example, some are not going after certain secondary diagnoses if it doesn’t affect the reimbursement. This could be a bad habit to get in to, she warns, because you won’t be able to capture the whole clinical picture or support resource use.

Now, nearly six months after ICD-10-CM/PCS implementation, here’s an opportunity for everybody to step back and realize that the data does matter, Schade says.

“We shouldn’t be neglecting to document or code something simply because the reimbursement won’t change. There are so many other factors that can be affected if the documentation isn’t as accurate as possible. The goal should be to be proactive, not reactive,” she says. “We have to stay on top of these things now, not wait until someone says this is a problem,” she says. “Pay attention now, or pay penalties later.”

Bottom line, hospitals should strive for complete and accurate documentation that leads to complete and accurate coding that shows the true clinical picture of the patient, says Schade.

“This is about representing the quality of care that we give our patients,” says Schade. “It’s important to get this right.”

A Note from the Instructors: Connecting with coworkers


Laurie Prescott, RN- MSN, CCDS, CDIP

By Laurie Prescott, RN- MSN, CCDS, CDIP

As many of you know, working remotely has its advantages: the commute to work is easy, you can attend meetings in your jammies, and who cares if you have a bad hair day? But it also has its disadvantages: you don’t get to see your coworkers’ smiles, give those hugs, or engage in laughter. That disconnect is one that we must work hard to eliminate, and that takes effort.

Earlier this month, the ACDIS team spent two days in our Danvers office making plans for 2016 and beyond (join us on Twitter for photos and other fun spur-of-the-moment notices). We are excited about what is up and coming. But perhaps the most valuable piece of the retreat was welcoming new team members, further getting to know each other, and appreciating our similarities and differences. We worked hard, and celebrated with good food and drink and fun. As I completed my “commute” home to Virginia, I was exhausted, but smiling thinking of the joy and energy we shared.

When work is joyful and fun, I believe it is at its most productive and creative state. I very much appreciate that I work for a company that understands this essential element for success and invests in providing an environment that fosters teamwork and creativity. So, I challenge you—especially those who work remotely—to make an effort to connect with a coworker today, learn something new about them, and identify ways in which your talents combined can better achieve the tasks at hand.

CDI has always been a profession in which we must creatively address issues and think outside the box— you can’t achieve success unless you work as a team, and everyone’s combined skills will achieve your goals. And you might experience a little joy in the process!

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, is the CDI Education Director at HCPro in Danvers, Massachusetts. Contact her at For information regarding CDI Boot Camps visit


Sunday Reading: Illustrating progress and failures

No matter what department or role you serve complete and accurate documentation should be one of your goals.

CDI specialists may have to get creative when it comes to sharing program outcomes with providers.

Sharing program outcomes with physicians is an important part of physician education. Many CDI programs do this at medical executive meetings or through other administrative sessions. They also use this forum to inform leadership of areas where documentation is lacking and ask the committee for guidance to help remove perceived barriers.

At this level, use actual data from public forms such as, CMS’ Hospital Compare, The Delta Group, Inc., state level quality sites, and regional insurer databases to illustrate how your specific facility fares against others in terms of key factors such as readmissions, length of stay (LOS), severity of illness, and mortality.

Such data illustrate to the medical staff how the general public views the care provided by the facility. If the data are not positive, if the actual mortality scores are higher than the expected mortality, the public will believe either the physician is incompetent, the facility is negligent, or both, and go to a nearby hospital for treatment in the future.

Save examples where physician(s) ignored or disagreed with a query that would have resulted in substantial MS-DRG impact and present those cases at either a general medical staff meeting or during annual CDI refresher sessions. Make sure to illustrate those diagnoses potentially missed due to lack of documentation specificity, how such lapses may have skewed the patient’s expected geometric LOS, the loss of potential reimbursement to the facility, and the effect on the physician’s specific score card (but be sure to redact the name).

Consider taking specific examples of physician documentation straight from progress notes to illustrate the impact of poor penmanship, inappropriate use of symbols, and lack of complete documentation to illustrate not only signs and symptoms, but also actual diagnoses of conditions. Maintain the educational intent of the display by removing any identifying marks (the names of the physician and patient and the dates) so only the clinical information remains. Walk the medical staff audience down the same path the documentation takes from physician’s pen to the CDI department. Illustrate how many queries were initiated and answered. Then explain what the coder chose and what the ultimate outcome was for patient severity and reimbursement.

Editor’s Note: This excerpt comes from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition by Marion Kruse, MBA, RN and Heather Taillon, RHIA, CCDS.