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2015 CDI Pocket Guide offers pediatric tips, new key references

2013 CDI Pocket Guide

2013 CDI Pocket Guide

The 2015 CDI Pocket Guide helps you take clinical findings and dig deeper, and look for additional details—such as medications and other conditions—to develop the most accurate picture of the patient’s condition.

Authors Richard D. Pinson, MD, FACP, CCS, and Cynthia L. Tang, RHIA, CCS, draw on more than fifty years’ cumulative experience and provide the clinical coding authority to strengthen patient care quality and resource utilization, and improve compliance and reimbursement.

The new 2015 edition of our popular CDI best-seller includes critical new updates from the 2015 IPPS Final Rule, and additional ICD-10 documentation tips to ensure you are ready for the national Oct. 1, 2015 compliance deadline. New to this year is additional information on Value-Based Purchasing (VBP) and how CDI specialists can incorporate VBP initiatives into their health record reviews.

What’s new in this edition:

  • Addition of pediatric clinical indicators and diagnostic criteria
  • New Key References for Shock, Neoplasms, Pneumothorax, Functional Quadriplegia, Cystic Fibrosis, Asthma, Intellectual Disability, and more
  • Standardized Key References format for each clinical topic: Definition, Diagnostic Criteria, Treatment, References, Coding and Documentation Challenges, and ICD-10
  • Content expansion of “MCC/CC” section to “Comorbid Conditions” that includes secondary diagnoses with a high impact focus for MS-DRG and APR-DRG, quality, and CMS Pay for Performance outcome metrics
  • Strategies for integrating CMS Pay for Performance initiatives into your CDI program
  • Expanded Reference citations of medical literature and other authoritative sources to support diagnostic definitions and criteria
  • Exclusive web-based resource center with detailed supplemental information and updates for all CDI Pocket Guide customers
  • Expanded and updated ICD-10 tips and strategies

TBT: Take another look at lung cancer cases to capture specificity

Look to clarify lung cancer concerns

Look to clarify lung cancer concerns

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo of you, something you most likely wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We’ve picked up the theme going back into our CDI archives to highlight some salient CDI tid-bit (rather than our fashion sense or lack there-of). Today, we’ve chosen to the CDI Journal article Take a closer look when reviewing lung cancer chartswhich originally published in the April 2011 edition.

by Helen Walker, MD

Lung cancer is the principal diagnosis in about 150,000 hospital admissions per year and a secondary diagnosis for roughly 386,000 admissions. Patients admitted with lung cancer either as a primary or secondary diagnosis require a longer length of stay than an average admission (source: Healthcare Cost and Utilization Project website, CDI specialists should know what to look for when reviewing cancer admissions in order to capture the true severity of these patients’ illnesses.

The ICD-9 codes related to lung cancer are assigned based on the following factors:

  • Documentation of a lung malignancy
  • Type of cancer
  • What part of the lung is involved
  • Whether the cancer is primary or secondary

Often patients are discharged with the diagnosis of “possible” or “probable” cancer when the pathology report is still pending. Although “probable,”  “suspected,” “likely,” “possible,” and “still to be ruled out” diagnoses can still be coded as a malignancy, it is best to have the attending physician provide documentation. The department in charge of the post-discharge query process (typically CDI or HIM) should query the physician if the pathology report returns after discharge.

The majority of lung cancers are non-small-cell carcinomas. These include the following:

  • Adenocarcinoma
  • Squamous cell carcinoma
  • Large-cell carcinomas
  • Non-small-cell/non-large-cell carcinomas

Thirteen percent of all lung cancers are small-cell carcinomas. Look for documentation to establish whether the lung cancer is primary or secondary. Many cancers metastasize to the lungs, including breast cancer,  gastrointestinal tumors, kidney cancer, melanoma, sarcomas, lymphomas and leukemias, germ cell tumors, and ovarian cancer. So if there is a question whether a tumor is metastatic to the lung, or from the lung, query the physician.

Note: Walker is vice president of clinical quality at FairCode Associates, LLC, a healthcare consulting firm specializing in DRG and coding audits. Contact her at

Q&A: Ensure query compliance by reviewing industry practice recommendations

Ask your question!

Ask your question!

Q: I was told that a multiple choice query should have at least four options. Keeping in mind that there may be only one reasonable option in a multiple choice query, what would be a good fourth option for a query about hyperkalemia if the other options are:

  1. Hyperkalemia
  2. Other
  3. Undetermined

A: There are many myths concerning compliant query practices so before automatically accepting a dictum of query parameters go back to the official sources to ensure compliance. By this I mean first reference the most recent guidance from the Association of Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS). AHIMA is one of the four cooperating parties (along with CMS, American Hospital Association, and the National Center for Health Statistics) so its recommendations have additional credence should auditors or other investigators question your CDI program practices.

According to the 2013 “Guidelines for Achieving a Compliant Query Practice:”

“Multiple-choice query formats should include clinically significant and reasonable options as supported by the clinical indicators within the medical record, recognizing that there may be only one reasonable option. Multiple-choice query formats should also include additional options such as ‘clinically undetermined’ and ‘other’ that would allow the provider to add free text. Additional options such as ‘not clinically significant’ and ‘integral to’ may be included on the query form if appropriate.”

If you still feel a fourth choice is needed perhaps the choice of “not clinically significant” could be offered. But this would depend on the circumstances of the particular patient encounter.

The 2013 practice brief also provides an option for yes/no queries. However, the brief does recommend that even in yes/no queries that additional options be included, similar to those recommended for multiple-choice queries.

“The ‘yes/no’ query format should be constructed to include the additional options associated with multiple-choice queries (i.e., ‘other,’ ‘clinically undetermined,’ and ‘not clinically significant’ and ‘integral to’). Yes/no queries may not be used in circumstances where only clinical indicators of a condition are present and the condition/diagnosis has yet to be documented in the health record. Also, new diagnoses cannot be derived from a yes/no query.”

Again, refer to the practice brief for additional circumstances where yes/no queries may be warranted and read up on previous practice brief recommendations for a better understanding of how queries should be formatted.


Florida ACDIS Chapter has Renewed Energy

Attendees at the November Florida ACDIS Chapter meeting

Attendees at the November Florida ACDIS Chapter meeting

After attending her first ACDIS national conference, Kimberly Richart returned to her CDI program energized. “I knew we had to get our state of Florida involved,” she says.

So Richart called surrounding hospitals asking to talk with CDI staff. Most didn’t know what CDI meant, few had a team in place. Nevertheless, she found enough interested people to hold a meeting. It had 17 attendees.

Today, the chapter has nearly 200 members and typically more than 30 attendees at each quarterly meeting. Shortly after its first meeting, the Florida ACDIS Chapter formalized its agreement with ACDIS National, elected a president, vice president, and secretary/treasurer. The team developed by-laws and created a state logo. Since that first meeting at Morton Plant Mease Healthcare, the chapter has met in all corners of the state from the Pensacola to Miami and those unable to travel attend virtually via webinar and teleconferencing when available.

“It is extremely important to keep up to date with the ever-changing information related to CDI and government healthcare reimbursement initiatives,” says Richart who stepped down from her leadership role following the Chapter’s meeting and election earlier this month.

“Our goal has always been to provide a cohesive bond between between CDI specialists professionals from the diverse clinical settings throughout Florida; to provide advocacy for the CDI role. This support is just so important.”

We want to thank outgoing Florida ACDIS Chapter leaders Richart, Edie Brown, and Jamie Dugan and welcome incoming leaders (pictured below) Colleen McComas, Cynthia Knight, Deb Dallos, and Joannie Crotts.


Incoming FL ACDIS Chapter leaders.

Incoming FL ACDIS Chapter leaders.

Advisory Board nominations due today

We are currently seeking four new ACDIS members to join our advisory board in 2015. ACDIS advisors are important, volunteer positions that help shape the direction of the association and provide leadership and expertise for the membership. The term of service is a maximum of three years.

The deadline for returning completed applications is Monday, November 17, 2014. A nominating committee and the ACDIS membership will make final selections by January 2015.

The role and expectations of ACDIS advisory board members is described on the advisory board page.

Please fill out and submit the application form by clicking here.

Book Excerpt: CDI in the Regulatory Environment

The Physician Advisor's Guide to CDI.

The Physician Advisor’s Guide to CDI.

Twenty years or so ago, CDI specialists might have been called record reviewers or had a title associated with “optimizing” the documentation in the medical record. In the course of the MS-DRG implementation and related documentation and coding adjustment payment decreases, CMS indicated in its FY IPPS final rule that there is “nothing inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment… supported by documentation in the medical record.” And so facilities began to formalize the CDI role.

As benevolent a mission as CDI may seem to have, for many facilities the focus of concurrent physician queries continues to be identifying information to increase reimbursement. When such efforts do not reflect the care provided to the patient or are conducted in a leading manner, these practices could be construed as fraud–particularly when data patterns appear to illustrate inconsistencies with national norms.

Of course, healthcare providers must ensure the financial solvency of their organizations, just as government officials must ensure the solvency of their healthcare funding programs. Both sides of this fiscal conundrum face growing financial frustration as both sides continue to search for an underlying cause to answer the dilemma of expanding healthcare costs.

Nevertheless, when a facility submits a claim to the federal government for payment of activities that were never provided, it risks being accused of False Claims Act violations, investigations by the office of the Inspector General and in some cases prosecution by the Department of Justice.

Editor’s Note: This excerpt comes from The Physician Advisor’s Guide to Clinical Documentation Improvement by Trey La Charité, MD, and  James S. Kennedy, MD, CCS, CDIP.