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Sunday Reading: Definitions to know when using the DRG Expert

The DRG Expert

The DRG Expert

The DRG Expert® includes an alphabetic index to diseases as well as a numeric listing of diseases (numeric by code assignment). Procedures can also be found listed both alphabetically and numerically. After each listing, there are identified page numbers.

The appendix of the DRG Expert® lists CC/MCCs both alphabetically and numerically. Since CMS’ CC/MCC designations may change annually, this section allows you to quickly identify any changes relevant to your patient population.

The DRG Expert® is not a code book or a medical guide book, so it does not provide an exhaustive list of terms.

If this is your first time using the DRG Expert®, there may be some terms you are not familiar with. Here are three definitions every CDI specialist should know when using the book:

  • GMLOS: The national mean length of stay for a DRG as determined by CMS. It is not a straight average but eliminates the outliers (very short or very long lengths of stay) from the equation. This allows organizations to compare their length of stay with a national benchmark.
  • ALOS: It is the simple arithmetic mean, or what most people refer to as the average; the lengths of stay for the patients in question are added together and divided by the number of patients. This equation does not remove the outliers from the mix.
  • RW: An algorithm which assigns a value to a condition or a procedure that is then adjusted based on a variety of additional factors, such as geographic location. It aims to quantify the expected resource consumption for a specific patient population. Payment for each DRG is based upon the assigned relative weight.

Having these definitions on hand can be a helpful resource for CDI specialists when assigning an MS-DRG code.

Editor’s Note: This excerpt was taken from the Online Materials in The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.

ICD-10 Tip of the Week: Ongoing Education

Physician signature legibility continues to be problematic.

We’ve said this before, but frankly cannot stress enough the importance of continued education post-implementation.

As calendar year 2015 comes to a close and 2016 begins, be sure department leaders continue to assess CDI and coder productivity and proficiency with the new code set. To do this, conduct CDI/coder satisfaction surveys and compare previous assessments, and continue to provide additional educational sessions as needed based on those assessments.

Many CDI teams will also be the frontline educators for physicians. The same concepts hold true. Continue to assess physician performance and identify target areas for education. Communicate with physicians about areas they struggle with and identify opportunities for additional education. Use a multidiscipline approach incorporating tips into physician newsletters, presenting targeted education during short PowerPoints presentations, and crafting tip sheets for top problem areas.

Any education must incorporate the main rationale for ICD-10-CM/PCS: to ensure the successful capture of additional specificity regarding care and conditions treated in America today. At the most basic level, education should highlight documentation requirements associated with appropriate coding. Lack of specificity affects the entire healthcare process. CDI specialists, in their efforts, have a valuable role to play.

Editor’s Note: This post was compiled using a number of ACDIS resources. For more information, check out the following:

TBT: Support your turkey

I've even seen turkey wrapped in bacon.

Once Dr. Carver sews up Tom, he’ll be ready for discharge to the oven, where we can roast him to perfection.

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo, something you most likely wish had been left unpublished. We’ve picked up the theme going back into our archives to highlight some salient tid-bit. Today, in honor of Thanksgiving, we’re throwing it back to this gem from our sister publication, the ICD-10 Trainer.

Tom Turkey has come in to the Stitch ‘Em Up Hospital for a little work before Thanksgiving.

Dr. Carver is going to first take out Tom’s guts, then replace them with stuffing. How would we code Tom’s procedures?

Let’s start with the organ removal. Dr. Carver is removing the entire organs, so we know our root operation will be “Resection.”

So, which body parts are we taking out of Tom? Well, let’s see. We don’t want the heart, lungs, liver, gizzard, gall bladder, crop, duodenum, ileum, jejunum, colon, and kidneys inside Tom.

In ICD-10-PCS, we would report a code for each separate body part. For example, if we are coding for the removal of Tom’s lungs, we would report code:

  • 0BTM0ZZ, Resection of bilateral lungs, open approach

If Dr. Carver only removed one lung, we would use either K (right lung) or L (left lung) as our fourth character.

We will do the same thing for the intestines. ICD-10-PCS includes separate body part values for the small intestine, as well as the duodenum, ileum, and jejunum. Because we are removing the entire small intestine, we would report 0DT80ZZ (Resection of small intestine, open approach).

If Dr. Carver removed part of Tom’s small intestine, we would use the body part character for the appropriate section:

  • 9, duodenum
  • A, jejunum
  • B, ileum

Read the operative report carefully, not only to identify the correct body part, but also to make sure you choose the correct root operation. Dr. Carver may only remove a section of the ileum or duodenum. In that case, we would report the procedure using root operation Excision (cutting out or off, without replacement, a portion of a body part), not Resection.

Once Dr. Carver has completed the internal organ removal, it’s time to replace them with supplemental material (also known as stuffing).

Which root operation would we use to report stuffing Tom? Our possibilities include:

  • Insertion—putting in a non-biological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part
  • Replacement—putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part
  • Supplement—putting in or on biologic or synthetic material that physically reinforces and/or augments the function of a portion of a body part

Since the stuffing is not really taking over the function of Tom’s missing body parts, it looks like Replacement is the closest match by intent. However, if you look at the ICD-10-PCS tables, you will notice that the tables for Replacement don’t include options for the complete organ. That makes sense because we don’t really have functioning artificial organs. And if the patient is receiving a new biologic organ, we would use root operation Transplantation (putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part).

If we were putting in stuffing to help support one of Tom’s organs, we would use root operation Supplement. For example, if we were shoring up his large intestine with stuffing, we would report 0DUE0JZ (Supplement large intestine with synthetic substitute, open approach). I went with a synthetic substance since stuffing isn’t really a biological material.

Again, you need to identify the specific body part because we have body part characters for the:

  • Large intestine as a whole (E)
  • Right large intestine (F)
  • Left large intestine (G)

We also need to look for two other elements for this procedure:

  • The approach
  • The supplemental material

The approach can be:

  • Open (0)
  • Percutaneous endoscopic (4)
  • Via natural or artificial opening (7)
  • Via natural or artificial opening endoscopic (8)

The type of material could be:

  • Autologous tissue substitute (7), which comes from the patient
  • Synthetic substitute (J), which is not biologically derived
  • Nonautologous tissue substitute (K), which comes from someone other than the patient

Once Dr. Carver sews up Tom, he’ll be ready for discharge to the oven, where we can roast him to perfection.

Q&A: CDI education for inpatient rehabilitation

Got a question? Ask us!

Got a question? Ask us!

Q: Our CDI nurses will be doing a presentation for our inpatient rehabilitation department, which includes physical therapy (PT), occupational therapy (OT), and speech therapy. We plan on providing an introduction to CDI—what it is, who we are, and the goals of our department—and, of course, we would like to address documentation specific to their department.

We will most likely mention that, although we cannot code based on their notes, it is helpful if they document specific words, such as “aspiration” or “L-sided hemiparesis” or “functional quadriplegia” so, in the event that we need to query the physicians, we can use their notes to support this.

Are we on the right track? Do you have any other ideas regarding documentation issues or concerns that we should include for this group?

A: Your question brings up a great point for CDI specialist and their role in education. Many people state that the education function of a CDI specialist is to teach the physicians about the needs for quality documentation. I do agree that the physicians are our primary focus, but I define our education responsibilities a bit differently. I feel it is our responsibility to educate everyone who documents in the chart.

As a CDI specialist, I called it my “CDI Roadshow” and visited as many different departments in the hospital that would welcome me, including nursing orientation programs and nursing staff meetings, and other departments such as PT/OT, respiratory therapy, dieticians, pharmacy, etc.

I agree you need to start with a basics—explaining why documentation is so important and how it influences your organization’s health to include both direct and indirect reimbursement, and reputation related to publically-reported quality data.

For the inpatient rehab department, I think your focus is spot on. I would encourage them to describe patient function, the presence of hemiparesis, and other neuromuscular deficits. Encourage them to ask and answer questions—is the patient prone to falls? Are there any anomalies related to gait?

Documentation of aspiration and swallow evaluations is also an important target. If your rehab department is involved with wound care, this may be an area for needed education.

I once had a dietician say to me, “You read my notes? I didn’t think anyone read my notes!” Let them know that you read their notes and how they are helpful to you. Good luck!

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

What can you submit as CEUs for CCDS recertification?

I'll never wear this pin but tomorrow I'll walk through the testing process.

You CAN use ACDIS conference CEUs for CCDS recertification!

Every now and again someone asks me a question that concerns me. Here is today’s troubling question:

Is it true that ACDIS conference CEUs cannot be used for my CCDS recertification?

The answer is NO! It is NOT true! It is FALSE!

Of course you can use ACDIS conference CEUs for CCDS recertification!

You have lots of options when it comes to recertification CEUs. You can earn 10 free CEUs each year for participating in the quarterly conference calls and completing the quizzes in the bi-monthly CDI Journal. You can use CEUs from any of the ACDIS CDI Boot Camps (online or live class programs).

There are many more options. We accept:

  • Nursing, AHIMA and AAPC CEUs CME credits for CDI-related training and education (ICD-10, clinical disease or diagnosis, coding, documentation improvement, diagnosis/pathology)
  • College course work relevant to healthcare/healthcare management, CDI or clinical coursework toward a degree
  • Presentations of CDI-related topics at seminars and speaking engagements—but not for presentations and training you deliver to coworkers

Here is a document that will help you know what you can submit for CCDS recertification. Be mindful of the restriction indicated on the recertification application.

Keep copies of the certificates you receive when you complete a training and submit them with your CCDS recertification application.

Editor’s Note: For more information, take a look at the recertification page on the ACDIS site. 

Guest Post: Look at the nuanced sepsis definitations before querying

Dr. Robert S. Gold

Dr. Robert S. Gold

By Robert S. Gold, MD

The incidence sepsis cases within the United States has quadrupled while the length of stay of these cases and the mortality has decreased. And Recovery Auditors have denied numerous claims because, at least in part, CDI staff queried to get sepsis DRGs when the patient didn’t have sepsis. While these professionals may have followed the letter of the law in terms of query compliance, they often do not follow the clinical letter of the law.

There’s sepsis and there’s alternative terms that are not sepsis.

Putting a patient on a “sepsis protocol” is not a diagnosis of sepsis. A sepsis protocol says the patient may have an infection and it may have advanced far enough to be serious and have systemic manifestations with increased risk of death, or it may turn out, after workup, that it wasn’t sepsis at all, or it may not be an infection at all.

A patient who has criteria of systemic inflammatory response syndrome (SIRS) has abnormalities in vital signs or abnormalities of lab tests. That alone is not sepsis under any circumstances—until it’s proven to be sepsis. Most patients do not exhibit the clinical indicators to even meet the criteria and, in many that did meet the criteria, the abnormalities had nothing to do with the infection.

Acute diverticulitis is acute diverticulitis. Acute otitis media is acute otitis media. Most bacterial infections have two of the four criteria of SIRS and most of these patients are not sick. Most patients seen in an emergency room with an infection and two of the four criteria that look like SIRS actually go home.

Using the term “sepsis syndrome” is another way of trying to get around truth. Once upon a time, “sepsis syndrome” actually meant sepsis; however it has evolved to be equivalent to SIRS and has no validity as a codable term at all until, and if, it is determined that the patient has actually has sepsis.  In fact, Coding Clinic even came to that conclusion in Second Quarter 2012 p. 21, and people who are assigning sepsis codes based on documentation of “sepsis syndrome” are taking quite a risk.

Editor’s note: Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician CDI programs, including needs for ICD-10. Contact him at 770-216-9691 or This article was originally published in the DCBA enewsletter CDI Talk.

Sunday Reading: Using the DRG Expert

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

Most CDI specialists quickly learn the value of the DRG Expert® in their daily practice. The DRG Expert® typically can be found sitting on a CDI specialist’s desk to assist with “all questions DRG related.”

Although most CDI specialists have access to an encoder, CDI staff need to have a general understanding of how to use the manual and how to employ the logic for assigning a DRG code. An encoder automatically applies rationale to “group” the assigned codes and identify principal and secondary diagnoses and procedural codes to a specific DRG.

The DRG Expert®, published by Optum, is updated annually to reflect any changes mandated by CMS in its inpatient prospective payment system (IPPS) final rule. Optum has varied it’s publication over the years, but the principal structure, format, and use of the manual has remained fairly consistent.

The first section lists the DRGs numerically, from DRG 001, Heart Transplant or Implant of Heart Assist System with MCC, to DRG 999, Ungroupable. This list identifies which major diagnostic category (MDC) the DRG belongs in as well as the page number for the full listing.

For example, DRG 682, Renal Failure with MCC, is listed in MDC 11, Diseases and Disorders of the Kidney and Urinary Tract. When you go to the page listed, it identifies DRG 682, Renal Failure with MCC, and provides information pertaining to the geometric length of stay (GMLOS), the average length of stay (ALOS), and relative weight (RW) of the DRG.

The entry for DRG 682 within the DRG Expert® indicates that DRG 682, Renal Failure with an MCC, has a GMLOS of 4.9 days, an AMLOS of 6.5 days, and a RW of 1.5862. Below this is a list of codes and principal diagnoses that map to this DRG. For example, a principal diagnosis of tumor lysis syndrome, oliguria and anuria, or acute kidney failure with lesion of tubular necrosis will map to DRG 682 if an MCC is also present.

Next on this same page is DRG 683, Renal Failure with CC, and 684, Renal Failure without CC/MCC. The same principal diagnoses listed under DRG 682 apply to these DRGs as well. The presence or absence of CCs and MCCs determines the final DRG assignment.

DRG Expert® also lists DRGs by MDC so you can identify which DRGs fall into what category. For example, DRG 163, Major Chest Procedure with MCC, falls into a surgical DRG within MDC 4, Diseases and Disorders of the Respiratory System. Curious about what procedures would fall into the major chest procedures? Turn to the page listed for DRG 163 for the listing.

Editor’s Note: This excerpt was taken from the Online Materials in The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.

ICD-10 Tip of the Week: Support your colleagues

team02In an email to ACDIS last month, Teri Ryan, RN, BSN, MBA, CCDS, Clinical Documentation Quality Reviewer at Aurora Health Care sent along this throw-back from former U.S. Secretary of Defense Donald Rumsfeld. He said:

“There are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns – the ones we don’t know we don’t know. And … it is the latter category that tend to be the difficult ones.”

The same may be said of ICD-10-CM/PCS implementation, Ryan suggested. HIM, coding, and CDI professionals have studied the code set, learned about the documentation improvement opportunities, and understand what the code set is all about. These are the things we know.

Yet, in the coming days, weeks, and months CDI query rates may rise, coders retrospective queries increase, and the number of cases discharged not final billed could incrementally increase, too. These are the known unknowns.

There are many unknown unknowns, as Rumsfeld put it. Will software and CDI programs work correctly (take a look at the CDI Talk string to hear how others have been faring so far)? How will our claims processing go two or three more months down the line? What will ultimately happen with ICD-10-CM/PCS code updates following the three-plus year moratorium and how will the new code set affect MS-DRG assignment?

And yet, as ACDIS Director Brian Murphy put it in a special letter to ACDIS members on go-live day, “the day has finally arrived. After years of delay, ICD-10-CM/PCS implementation is here. Implementing it will be a challenge, but one we believe is worth the struggle.”

Murphy went on to acknowledge the vital role that CDI professionals play in the code sets’ role out and encouraged those working in the field to continue to share their stories, struggles, and successes with ACDIS.

ACDIS was founded on, and has grown from, the generosity of its members. Simple quotes, like the one above from Ryan, and tales from your CDI programs’ front lines, offer others insight, hope, positive feedback, and inspiration they can take back to their own facilities.

Karen Gray, RN, CCDS, from Salem Health System in Oregon, sent along some photos of her facility’s activities on go-live day. The team all wore matching “lifeguard” tee shirts, set out buckets of lifesaver candies, decorated balloon with ICD-10 themes, and even posted Halloween-themed ICD-10 messages. They had fortune cookies made with ICD-10 documentation tips and rounded the hospital floors to check-in with their physicians and make sure everything was going okay. The group really tried to embrace the day and keep it from being something scary, Gray explained.

To bring some Halloween-fun to the ICD-10-CM/PCS implementation process, the folks at Munson Healthcare in Cadillac, Michigan dressed as a code. You can see their photos on our Facebook page.

“We know the vital role you as CDI professionals play in ensuring your facility’s transition to the new code set, and trust that you’ll be successful in your endeavors,” Murphy wrote.

Please send us your photos, success stories, trouble areas, and any sample education materials or query templates your team may be developing to donate to the Forms & Tools Library.

“We’d love to hear from you and sharing experiences with your colleagues and members is a big part of what ACDIS is all about,” Murphy wrote.

TBT: Putting partisan politics aside, even in CDI

When you think of "politics" in terms of who gets what piece of the pie, the CDI profession may take on a larger role in the healthcare vision.

Unfortunately at many facilities, this national situation with partisan politics also plays out amongst the various healthcare silos.

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 Associate Director’s Note in the Nov. 20, 2014 issue of CDI Strategies, “Putting partisan politics aside, even in CDI.”

Unfortunately at many facilities, this national situation with partisan politics also plays out amongst the various healthcare silos. Physicians balk at transitioning to electronic health records and ICD-10-CM/PCS implementation, coders cringe at what they perceive to be CDI infringement, and CDI specialists hailing from bedside care flinch when asked to curb their clinical involvement or expand their efforts beyond CC/MCC capture.

And yet, just like effective government, effective patient care (and the soon-to-come population management of that larger global healthcare) depends on the cohesive, cooperative efforts of these three critical branches—physicians, CDI specialists, and coders—to work together in solving healthcare’s documentation woes.

Where conflict does occur, CDI specialists need to take the high-ground and identify ways in which their acumen can help solve the problems of the communities they serve. That may mean reaching out to particularly troublesome physicians or digging into data to identify ways the CDI department can help coders solve a thorny ongoing documentation problem. It may mean reaching beyond the current scope of practice to identify documentation needs related hospital acquired conditions, mortality data, or denials management.

In working together to solve one-another’s most pressing needs we can help elevate not only the content of the medical record but actual patient care provided in facilities nationwide.

For additional insight consider reviewing the 2012 ACDIS conference presentation “How partnership with medical directors, clinical integration specialists, and coders impacts patient care,” or the 2010 ACDIS Conference presentation “The clinical/coding reconciliation process.”

The following related articles are available under the CDI Journal section of the ACDIS website:

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

Don't get overwhelmed! Just ask us for help! Leave your question in the comments section below.

Don’t get overwhelmed! Just ask us for help! Leave your question in the comments section below.

Q: I have seen documentation of oliguric renal failure and non-oliguric renal failure. What is the difference and does it impact coding?

A: We can define acute kidney injury (AKI) in terms of serum creatinine stages but we can also define it in terms of urinary output. Now the term “oliguric renal failure” is one we use where people have AKI but their urine output is less than normal.
Normal urine flow should be greater than a liter a day. If you have 500 cubic centimeters up to a normal amount of urine output in a day, then that’s what we call non-oliguric renal failure, because the patient is putting out urine. These people tend to have less injury to the kidney and have greater survival statistics and so forth.

Now if the patient’s urine flow is below 500 cc a day and this is in the face of adequate fluid replacement, then the patient is not making urine appropriately and we call those people oliguric. That indicates that the patient probably has a more severe expression of the AKI or the acute tubular necrosis.

Now if you get below 50 cc, we call that anuric. We don’t see that very often in AKI or acute renal failure but when we do, patients typically have massive necrosis and a lot of times these people have cortical necrosis. The whole surface of the kidney is ischemic. But you also can see it in bilateral urinary obstruction from tumors in the pelvis. Again, the typical AKI doesn’t produce anuria. But oliguric renal failure is not uncommon and providers try to catch people early and convert them from oliguric to non-oliguric. However, this only relates to urine flow and it really doesn’t change how you code it at all.

Editor’s Note: This article was originally published in JustCoding. Garry L. Huff, MD, CCS, CCDS, AHIMA-approved ICD-10-CM/PCS trainer and president of Huff DRG Review in Eads, Tennessee, answered this question on the HCPro webcast “Acute Kidney Injury: Use Case Studies to Improve Renal Coding, Querying.”