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CCDS Update: DRG Expert and the CCDS exam

The DRG Expert

The DRG Expert

Q: Which edition of the DRG Expert do I need for the Certified Clinical Documentation Specialist (CCDS) certification exam?

A: It depends on when you plan to take the exam. 

If you take the exam BEFORE mid-January 2016, you will be taking the ICD-9 version. You will need an ICD-9 edition of the DRG Expert and may use the 2013 or 2014 edition. If you don’t have one, borrow one from the coding department. It is your responsibility to be sure the DRG Expert you bring in is ICD-9 based.

IDC-10 takes effect October 1, 2015. Our exam changes in mid-January 2016. We want ICD-10 to be in place for a few months before we start testing people on it. We will confirm the exact date for the change to the ICD-10 CCDS exam as soon as we can.

If you plan to take the exam AFTER the mid-January change, you will need an ICD-10 edition of the DRG Expert and either the 2015 or 2016 should be fine. It is your responsibility to be sure the DRG Expert you bring in is ICD-10 based.

Make the CDI Pocket Guide Even Better 


The 2015 CDI Pocket Guide. The 2016 version is coming soon!

The 2016 CDI Pocket Guide update is under development, and we’re always looking for customer feedback to make it even better.

Please share your suggestions and any “wish list” items with us at

To learn more about the CDI Pocket Guide, check out the 2015 version on the ACDIS/HCPro Marketplace.

We look forward to hearing from you!

Richard D. Pinson, MD, FACP, CCS

Cynthia Tang RHIA, CCS,

HCQ Consulting

TBT: Stop feeding the ‘EHR reimbursement beast’

Glenn Krauss

Glenn Krauss

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memes, Throw-back Thursday generally means sharing an old high school photo, something you likely wish had been left unpublished.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 July 2013 CDI Journal,CDI goal: Documentation for the physician and the hospital” by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS.

What is the goal of a CDI program? Most of the ones I see still focus on DRG optimization. Unfortunately, they are not preparing for ICD-10 and not supporting the physician with his or her professional billing. Very rarely do I hear about programs that help with the core question, “What’s in it for the physician?” And that’s our biggest problem. We need to make the physicians allies of our CDI programs, and right now they are not. Instead, they are often targets of our queries.

So how do you make the transition? By changing physician behavior one encounter at a time and letting them see that additional documentation helps with their professional billing.

Recently I spoke with a surgeon missing some important documentation from his consult notes. I provided him information about history of present illness (HPI) and why it was important to his evaluation and management billing. He thanked me, but his words were more telling than his gratitude: “This is great information. I’ll do better next time so I can continue to successfully feed the EHR reimbursement beast.”

Think about it: Isn’t that what we’re really doing when we’re asking for CCs and MCCs, “feeding the EHR reimbursement beast” with a diagnosis?

To change this paradigm, we need to ask about the context, not just the diagnosis. When reviewing the charts, consider asking:

  • What is the clinical context in the chart supporting the diagnosis of record?
  • Does the HPI in the history and physical support the diagnostic assessment of the physician, corroborated by nursing documentation and chosen plan of care?
  • Is the physician’s clinical rationale, judgment, and medical decision-making in arriving at the diagnosis using available diagnostic information clearly depicted in the chart? Or is it instead implied through sporadic bits and pieces of documentation in the electronic health record (EHR)?

Q&A: How should we prepare for PCS?  

Ask your question!

Ask your question!

Q: How can our CDI team prepare for potential productivity losses post-ICD-10 implementation, specifically regarding procedure codes (PCS)? Should we consider hiring additional staff, or staff with a surgical background?

A: I agree that use of ICD-10 will affect coding productivity, and also CDI productivity, primarily due to the technical features of PCS.  However, I feel adoption of [new diagnosis codes] (CM) by coders and CDI staff will be fairly easy.

Using surgical templates for high-volume procedures can make the transition to PCS easier. These templates could ask the surgeon to identify devices, grafts, and other qualifying information [that CDI and coders need to document to the highest specificity]. For example, was the stent bare metal or drug-eluting? Or was cement used for the arthroplasty?

I do not think we need to use people with surgical experience to help us with the PCS coding, as knowledge of anatomy and physiology should suffice. I have found that the extremely granular requirements of PCS coding can make proper MS-DRG assignment challenging in certain situations. This factor will impact CDI and coding DRG match efforts.

I think the most pertinent value and mission for CDI professionals is accurate documentation of diagnoses, but we can selectively query for some PCS procedures.

Editor’s Note: Paul Evans, RHIA, CCS, CCS-P, CCDS, Manager of Regional Clinical Documentation & Coding Integrity at Sutter West Bay in San Francisco, answered this question. Contact him at, or connect with him and other CDI professionals on CDI Talk.

Guest Post: New Law Puts Providers on NOTICE

Debbie Mackaman

Debbie Mackaman

by Debbie Mackaman, RHIA, CPCO, CCDS, regulatory specialist for HCPro

While many providers are still digesting the IPPS Final Rule, muddling through how the OPPS Proposed Rule might impact their bottom line, and kicking rocks because the 2-midnight rule was not chucked, President Obama signed a bill into law on August 6, 2015—and it’s one providers should note. Unanimously approved by both the House and Senate earlier this year, the Notice of Observation Treatment and Implication for Care Eligibility Act, otherwise called the NOTICE Act, will not take effect until August 2016, but will certainly add one more layer to the administrative burden associated with outpatient observation services when it does.

Public Law 114-42 will amend the Social Security Act and require a hospital or critical access hospital (CAH) to provide the beneficiary with a written notice when they receive outpatient observation services for more than 24 hours. The notice must be provided within 36 hours of the start of observation, which would coincide with the order for such service, or prior to discharge or transfer, whichever occurs first after the initial 24 hours has been reached.

Hospitals and CAHs currently provide many “notices” to the patient, including a financial consent, consent to treatment (procedure, anesthesia, blood transfusion, etc.), release of information, Important Message from Medicare (IM), Detailed Notice of Discharge (DND), Advance Beneficiary Notice (ABN), and the Hospital Issued Notice of Noncoverage (HINN)—just to name a few. The regulation clarifies that this notice will not be in “hit and run” form, as it requires hospital staff to provide an oral explanation of the implications of remaining in outpatient status.

As hospitals begin to draft the notice and develop a process for issuing it, they should also consider who will be responsible to eloquently explain the situation to the patient. Key elements of the notice must include a written and oral explanation stating:

  1. The patient is an outpatient and not an inpatient of the hospital and the reasons why;
  2. The implications of remaining in outpatient status, primarily the related financial issues including deductible, coinsurance, and items or services not covered by Medicare, such as self-administered drugs; and,
  3. All time spent as an outpatient, including observation services provided on the inpatient floor, will not count towards the 3-day acute care qualifying stay required for coverage of a subsequent skilled nursing facility (SNF) stay, if appropriate.

The notice must be written in easy-to-understand language and available in “appropriate languages.” This requirement is not further specified in the law, although the IM, DND and ABN notices can only be provided in English or Spanish versions, so more clarification will be needed. At this point in time, it is unclear if CMS will provide standardized language similar to that used to inform the beneficiary and the provider about the financial liability protections under the Fee-for-Service (FFS) Medicare and, in certain cases, the Medicare Advantage (MA) Programs.

The notice must also be signed by the patient or the person acting on behalf of the patient and the hospital staff member who presented the notice. If the patient or his or her authorized representative refuses to sign the notice acknowledging their outpatient status, the hospital must indicate on the refusal on the form and include the name, title, and signature of the staff member issuing the notice, as well as the date and time of the refusal. This procedure is similar to recommendations CMS has provided when a patient refuses to sign an ABN. However, refusing to sign the new notice does not release the beneficiary from any financial obligation.

As hospitals incorporate the new regulation into their current processes, they should also be acutely aware of the 2-midnight benchmark and the implications of keeping patients in outpatient status receiving observation services for more than 24 hours. CMS has stated that they do not expect a Medicare patient receiving medically necessary hospital care to pass a second midnight without an order for inpatient care. Providing the new notice to the patient should not only serve to inform them of their potential financial liability as an outpatient but also to put the hospital and the attending physician on notice regarding the correct application of the 2-midnight rule.

Editor’s Note: This article originally published in HCPro’s Medicare Insider eNewsletter.

Q&A: Exploring HCAP, A Physician Documentation Dilemma

Richard D. Pinson, MD, FACP, CCS

Richard D. Pinson, MD, FACP, CCS

Q: If the physician documents “HCAP” is that sufficient to be able to code a gram negative and/or pneumonia?

A: If the physician documents “HCAP” the code defaults to 486, unspecified pneumonia. When this is the principal diagnosis, it results in DRG 193-195, simple pneumonia. Documentation of suspected/likely/etc. gram negative pneumonia, or organisms, results in code 482.83, other gram negative pneumonia. This is assigned to DRG 177-179, respiratory infections.

Q: Can you please clarify whether or not HCAP and CAP can be used for coding purposes, and if we should query for the specific organism?

A: In both ICD-9 and ICD-10 classifications, HCAP and CAP default to code 486, unspecified pneumonia, and therefore DRG 193-195, simple pneumonia, is assigned if it is the principal diagnosis. CAP belongs in DRG 193-195, and therefore does not require further specification of causative organism for a clinically correct DRG assignment. HCAP represents a much more complex, severe type of pneumonia caused primarily by staph and gram negative organisms, most appropriately described by DRG 177-179, respiratory infections. The most probable/suspected/likely organism(s) causing HCAP must be documented to allow correct coding to these DRGs.

Q: Is there any coding guideline that states you must have a positive sputum culture to code gram negative PNA, even when documented by a physician?

A: No, although in that case one would expect the diagnosis to be qualified with some term expressing the degree of certainty such as probable, suspected, likely, etc. Code assignment is based on consideration of all the documentation and information contained in the medical record taken in its full context and the “clinical validity” of documented diagnoses, meaning the findings are consistent with medical professional diagnostic and treatment standards and/or evidence-based medical literature.

Q: When the physician does not mention the organism in the final impression, can we consider the labs, or does the physician have to document it in the final impression?

A: Culture results alone cannot be used for code assignment. The documentation of the probable/suspected organism(s) is not required in the discharge diagnoses if documented elsewhere in the record, is clinically consistent with the diagnosis, if there is no evidence that the probable/suspected cause has changed “at the time of discharge,” and it was treated with a full course of indicated antibiotics for staph and/or gram negatives.

Editor’s Note: Richard D. Pinson, MD, FACP, CCS, co-founder and Principal of HCQ Consulting, answered these questions, as part of a supplement to our July 9, 2015 webinar, “Exploring HCAP: A Physician Documentation Dilemma.” For more information and access to a complete version of this Q&A, click here.

ACDIS Update: 2016 Conference Speakers Sought, 2015 Conference Recap Posted

Just as parents aren’t supposed to pick favorites, I really shouldn’t call out one conference experience as “better” than another. Johnny may excel at sports and Sally may dominate in spelling, but each has unique talents. So it goes with ACDIS. Las Vegas in 2014 had its glitz. San Diego in 2012, with its bay side balconies, had its foggy charm. Chicago in 2010 had its parade of educational offerings and boat-trip networking fun. And yet … as the ACDIS Conference team boarded a San Antonio river boat to celebrate on the final day, the general consensus soon turned into a chorus of praise. The 2015 conference in
San Antonio—our biggest conference yet, with roughly 1,500 attendees—will definitely have a special place in our hearts. Why? Well, there were a number of reasons that you can read more about in the 2015 ACDIS Conference Special Section posted under the July edition of the CDI Journal (but you can take a look at the edition below).

While I know the San Antonio ACDIS Conference was amazing, I also know that there are many more CDI success stories waiting to be shared. We’re looking forward to hearing from you and seeing you on stage at the 2016 ACDIS Conference in Atlanta.

Click here to view the speaker application.

For more information on the types of presentation sought for the 2016 event, visit the ACDIS Blog.

The speaker application period closes end of day on Tuesday, September 1. All final decisions will be made by the 2016 ACDIS conference committee and applicants will be notified of their decision in October.

Guest Post: Volume overload in ESRD patients

detective-with-footprints-300x240By Robert S. Gold, MD

A patient with end-stage renal disease (ESRD) comes into the ED with volume overload, identified by increased swelling of the legs and slight shortness of breath. Chest x-ray shows some pulmonary edema. Studies show a creatinine level of 9.8 that went down to 4.5, hemoglobin of 10.5, and BNP of 25,000. The patient is admitted for dialysis, gets rapid relief, and is discharged the next day. Coders assigned the following ICD-9-CM diagnoses, among other codes:

  • 403.91, hypertensive renal disease with chronic kidney disease (CKD) stage 5 or ESRD
  • 585.6, ESRD
  • 514, pulmonary congestion and hypostasis
  • 428.33, acute on chronic diastolic heart failure
  • 285.29, anemia of other chronic disease
  • 584.9, acute kidney injury (AKI)

Somewhere in the chart we noticed history of congestive heart failure, so the CDI team member queried the physician using the evidence of a BNP of 25,000 and previous echo demonstrating ejection fraction of 65%. The CDI specialists asked whether these two pieces met the criteria needed for acute on chronic diastolic (heart failure with preserved ejection fraction) heart failure. Other conversations included that the creatinine dropped from 9.8 to 4.5, a greater than 0.3 drop and certainly a 50% improvement in renal function, so acute kidney injury must have existed. The CDI specialist argues that the patient’s hemoglobin was only 10.5, so it was probably anemia of the patient’s chronic disease. And the pulmonary edema documented in the ED physician’s note, having been seen on the chest x-ray and copied and pasted on every progress note, must be 514.

Wrong! As a CDI specialist you shouldn’t  jump at numbers but look at the total patient, the clinical evidence, and use clinical thinking.

People with ESRD who are on dialysis, people who don’t have renal function, can’t go into acute renal failure. There’s nothing left to fail. The change in creatinine level was caused by dialysis removing nitrogenous products from the bloodstream. That’s all. This patient’s renal function didn’t change.

People with ESRD constantly have higher-than-normal levels of fluid in the bloodstream. Why? They can’t get rid of the fluid in the urine—they’re not making urine. So the venous circulation fills up with fluid.

When the right atrium gets stretched by volumes of fluid in the right side of the circulation, it stretches every day. And when the atria of the heart stretch, BNP is produced so that the body can try to urinate the extra fluid. That’s the normal mechanism in everybody. But the kidneys don’t work, so the stretch stays there and it gets worse. The BNP level rises and rises. These people walk around with BNP levels in the thousands, ten thousands, hundred thousands every day, and they’re not in acute congestive heart failure at all. It’s their new baseline. Get over it. Check their last 20 BNP levels; it’s the same high level.

Are you kidding about 514? I have ranted enough about 514. I’m tired of ranting about 514. But I’ll keep on ranting about 514 until someone gets it.

Pulmonary congestion and hypostasis was invented in the early 1800s (it was called 94 at that time). It defined a finding at postmortem exam of some people who had lain without moving with minimal nutrition for extended periods of time while they died of something, whether cancer or tuberculosis or leprosy. The pathologists who performed the autopsies on these patients gave it several descriptive names, including pulmonary congestion, pulmonary edema, hypostatic pneumonia, and apoplexy of the lung. Here is an excerpt from the Manual of the International List of Causes of Death from 1909:

Pulmonary congestion, pulmonary apoplexy. This title includes:

  • Active congestion of lung
  • Apoplexy of lung
  • Collapse of lung (3m+)
  • Congestion of lung
  • Dropsy of lung
  • Engorgement of lung
  • Hyperemia of lung
  • Hypostatic congestion of lung pneumonia

None of these terms were ever designed to be diagnoses. They were all ways that pathologists described the lungs in these patients. And the instructions for codes, which represented signs and symptoms and findings on autopsy of patients who died, were to NEVER assign such codes for a patient. Here again is a quote from the instructions on coding for death certificates from that time (emphasis added):

(d) The physician may indicate the relation of the causes by words, although this is a departure from the way in which the blank was intended to be filled out. For example, “Bronchopneumonia following measles” (primary cause last) or “Measles followed by bronchopneumonia” (primary cause first). 2. If the relation of primary and secondary is not clear, prefer general diseases, and especially dangerous infective or epidemic diseases, to local diseases. 3. Prefer severe or usually fatal diseases to mild diseases. 4. Disregard ill-defined causes (Class XIY), and also indefinite and ill-defined terms (e.g., “debility,” “atrophy”) in Classes XI and XII that are referred, for certain ages, to Class XIY, as compared with definite causes. Neglect mere modes of death (failure of heart or respiration) and terminal symptoms or conditions (e.g., hypostatic congestion of lungs).

In our case, pulmonary edema was an x-ray finding and not a diagnosis at all. It was evidence of volume overload, which the physician diagnosed.

And finally, the anemia of chronic disease. We have no code for anemia of chronic disease. Code 285.29 is not anemia of chronic disease. We have code 285.21 for anemia of CKD (which is what the physicians were actually talking about, but somebody told them of “anemia of chronic disease”), 285.22 for anemia of neoplastic disease, and 285.29 for anemia of OTHER chronic disease—you tell us which other chronic disease the patient has. If you can’t, it’s not 285.29, period.

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 article originally appeared in the HCPro website

Medicare Compliance Forum includes CDI focus

MCF includes sessions for CDI professionals.

MCF includes sessions for CDI professionals.

If you just can’t get enough of former ACDIS CDI Education Director Cheryl Ericson, MS, RN, CCDS, CDIP, consider joining her and fellow speakers Deborah Hale and John Zelem for the 2015 Medicare Compliance Forum in Charleston, South Carolina, October 27-28. 

The 2015 Medicare Compliance Forum addresses the ever-changing reimbursement landscape and has six tracks to choose from (three each day),  covering Medicare billing and compliance, as well as challenges facing case managers, clinical documentation improvement specialists, utilization review professionals, and more. Here’s a look at the CDI-related sessions being offered.

Document, Document, Document: Enhance Documentation to Drive Meaningful Data
Cheryl Ericson, MS, RN, CCDS, CDIP

Providers need more than just being told to “document” because not all documentation in the medical record is created equal. Most medical records contain pages and pages of words, but much of this text is repetitive and doesn’t translate into meaningful codes, which in turns fails to support medical necessity. This session will take a look at when documentation has meaning by exploring the general concept of medical necessity and its relationship to coded data.

Is Your Readmission Problem Really a Documentation Problem?
Cheryl Ericson, MS, RN, CCDS, CDIP

This session will present an overview of the impact of coded data on CMS quality initiatives, which are also known as pay-for-performance. Participants will be introduced to the CMS quality initiatives of the Hospital Value-Based Purchasing Program, the Healthcare-Acquired Condition Reduction Program, and the Readmission Reduction Program, and how CDI efforts can support accurate reporting of these measures based on administrative data. Key documentation issues associated with the CMS quality initiatives will be presented.

Clinical Documentation Improvement and the Quality Mandate
Deborah K. Hale, CCS, CCDS

Value-based purchasing (VBP) is an important step to revamping how healthcare services are reimbursed in the Medicare program, and it is emerging in the commercial insurance market. Clinical Documentation Improvement for risk adjustment and accurate representation of the patient’s precipitating factors are critical to financial and marketing success. This session will demonstrate Clinical Documentation Improvement targets for risk adjustment and for achieving success with VBP initiatives.

The Role of CDI and the EHR in Supporting Medical Necessity
John Zelem, MD, FACS; Cheryl Ericson, MS, RN, CCDS, CDIP

CDI specialists are often tasked with reviewing the medical record to ensure documentation is comprehensive. However, the use of EHRs can minimize the utility of the health record as documentation often becomes generalized and repetitive. CDI specialists and coders face challenges associated with organizational implementation of meaningful use (e.g., problem lists, computer physician order entry, and the ability of providers to copy and paste documentation). Explore some of the challenges associated with provider documentation resulting from the increased use of technology.

TBT: Communicate CDI directives consistently across hospitals in multi-facility programs

Methodist Le Bonheur Healthcare

Methodist Le Bonheur Healthcare

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. We’ve picked up the theme, going back into our archives to highlight some salient tid-bit. This week, we looked at an article from our July 2012 CDI Journal, “Four tips to tackle multi-facility CDI management.” 

CDI specialists working within a single facility often meet weekly to talk about any difficult records or problems with reviews. They also often sit near each other when not out on the hospital floors and may have team meetings or face-to-face interaction with each other daily.

At Robert Packer Hospital in Sayer, Pa., “it is easy to walk down the hall and talk to my staff,” says Susan Tiffany, RN, CCDS, CDI program supervisor for Guthrie Healthcare System in Sayre, Pa., “but I have to remember that what I say to one group of individuals also needs to be communicated to the rest of my staff.”

To keep CDI staff on the same page, Meg McGill, RHIA, corporate director for HIM at Methodist Le Bonheur Healthcare in Memphis holds monthly meetings for all CDI staff with the coding director and two lead coders who also attend. CDI specialists also meet monthly by facility with their immediate directors to discuss productivity, statistics, and facility concerns.

“Communication is definitely one of the big challenges,” says McGill. “You need to be sure you say the same thing individually that you say to the entire group. You have to have open communication and you have to get to know your staff. When concerns come up, they can talk to you one-onone, pick up the phone and call you, schedule an appointment, or send you an email. Be sure to make time for that. But otherwise I really rely on email.”

So does Bonnie Epps, MSN, RN, manager of CDI at Emory Healthcare in Atlanta. “It is not often I get to meet face-to-face with each staff member,” she says. “We all work pretty independently. I trust them to do their best and we mostly communicate by email.”

Staff members do meet monthly at individual facilities and quarterly for training and other meetings, with those from smaller facilities traveling to Emory’s main campus.

At Methodist Healthcare, however, McGill plans to have her new manager spend at least some time in every facility on a monthly or bimonthly basis. “The better you know someone, the easier it is to communicate,” she says.