RSSRecent Articles

Local Chapter Update: California ACDIS Chapter hosts first in-person event

The California ACDIS Chapter hosted its first in-person conference on Friday, June 26, 8 a.m. to 2 p.m., at Henry Mayo Hospital in Valencia. The chapter has been going strong for nearly six years now. Initially, there were three separate groups for each distinctive region of the state. After a few months, however, the northern and southern sections joined the central group for its monthly web-based networking groups. After three years, the time came for a leadership change and new volunteers stepped forward.

The new team changed meetings from a monthly to bi-monthly cadence and began recruiting help in the form of speakers and leadership assistance from its state-wide membership. Soon, the leadership swelled from three to nearly a dozen. Each volunteer agreed to take on a specific task and before long the chapter began planning a live full-day event for the state.

We gratefully acknowledge their efforts and congratulate the team for an amazing day of networking and education for the nearly 200 attendees.

Check out these photos from the event [more]

Guest Post: Wrapping your CDI arms around ICD-10-CM/PCS

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

ICD-10-CM/PCS doesn’t have to be met with apprehension in your CDI department.

by Karen Newhouser, RN, BSN, CCDS, CCS, CCM

ICD-10 CM/PCS.  To some, the utterance of this classification system produces much trepidation. I hope to dispel some concerns as I recount the undertaking of ICD-10 implementation at one CDI program.

First, please understand that I am not here to de-emphasize the seriousness of ICD-10-CM/PCS, but rather to equip you with a roadmap of tips and hints as you embark on this journey.

Yes, CDI specialists’ productivity will likely decrease, mostly due to the sheer volume of queries needed for the added specificity vital for correct code assignment. The act of query writing, no matter how experienced one may be, takes time. I feel, though, that with preparation and open channels of communication, the impact on productivity can be assuaged, however.

This case example CDI program is housed within the HIM department of a large Midwestern hospital [more]

Sunday Reading: Diagnostic Testing

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

Review the results of laboratory testing, cultures, imaging results, electrocardiogram, and rhythm strips in search of significant abnormalities and then determine whether supporting documentation exists for treatment with medications, fluids, oxygen administration, or further testing to confirm the significance as a code-able condition.

Coders cannot assign a code based on test results. However, such clinical indicators support a CDI query and help ensure query compliance. Always search diagnostic and imaging studies for clinical indicators to support existing diagnoses, to support further specificity of existing diagnoses, or to support queries for missing diagnoses significant to the patient encounter.  [more]

ICD-10 Tip of the Week: Assess your readiness

Regulatory changes make CDI and coding accuracy more important than ever

Be honest with yourself, and assess how prepared your CDI program is for ICD-10.

It’s pretty uncommon for a facility to feel they are over-prepared for ICD-10. However, it is common for facilities to think they are more prepared than they actually are. With less than 100 days before ICD-10 implementation, CDI specialists need to be honest with themselves, and accurately evaluate their program’s readiness. This is no time to underestimate your abilities to adapt to ICD-10-CM/PCS.

So, assuming you’re educational efforts have already begun, how do you assess how far along your facility is in terms of ICD-10 readiness? First, try breaking down ICD-10 preparation into sections, or specific items that facilities should address before implementation. For example [more]

TBT: Addressing the “See previous day’s note” in physician documentation

You CAN get physicians to support your CDI program.

CDI specialist can help physicians improve their documentation practices.

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’re throwing it back to an article by Trey La Charité, MD, physician advisor for clinical documentation integrity and coding at the University of Tennessee Medical Center, from the CDI Journal, “Addressing the ‘bad’ and ‘ugly’ in physician documentation.”

“See previous day’s note.” Many physicians document “see previous day’s note” for their assessment and plan section of a daily progress note. Physician time constraints are always a legitimate and sensitive subject; physicians are simply trying to reduce their workload by not repeating something they feel was done adequately the day before. Understandably, they feel it is redundant to repeat everything written the day before if there is no significant change in the treatment plan for that day. This becomes a problem for coders if the physician has a detailed problem list on the day of admission, all of the subsequent days’ progress notes say “see problem list from admission,” and the discharge summary lists only one main reason for admission.  [more]

Boot Camps: From CDI basics to ICD-10 details

What lesson learned do you have to share? Your peers are waiting to hear your insight. Submit your ideas for the 2014 ACDIS National Conference now.

Get the training you need at one of our CDI Boot Camps

We’ve had a number of calls recently asking us about our various CDI Boot Camp offerings. As you might guess, people are busy getting ready for ICD-10-CM/PCS implementation, and, between hiring new staff and reviewing ICD-10 opportunities, there’s a bit of a scramble going on for educational resources.

If you haven’t planned your training yet, here’s a list of where our Boot Camps will be over the next few months, and what you can hope to gain from each.

The Clinical Documentation Improvement Boot Camp offers an overview of everything you need to know to launch a successful CDI career, or boost your existing CDI program. [more]

Guest Post: Decipher encephalopathy coding and documentation challenges

Don't neglect nursing notes and nursing education when looking to strengthen your CDI program efforts.

To make the diagnosis audit proof, the physician needs to document the etiology of the encephalopathy.

“Encephalopathy is a great big monster,” says Timothy N. Brundage, MD, CCDS, medical director of Brundage Medical Group in Redington Beach, Florida. Coders and clinical documentation improvement (CDI) specialists want physicians to document encephalopathy, when appropriate, because it is an MCC.

By definition, encephalopathy is a global cerebral dysfunction in the absence of structural brain disease, Brundage says. “That definition is very nebulous.”

Unfortunately, providers often describe encephalopathy instead of diagnosing it, says Cheryl Ericson, MS, RN, CCDS, CDIP, [more]

Sunday Reading: Query Reviews

Start educating physicians now

The CDI’s Guide to ICD-10

Query forms themselves in many cases will help start ICD-10-CM/PCS-related conversations and educational opportunities with providers. Medical staff should be involved in the ongoing creation and review of query forms.

As is the case with ICD-9-CM, the medical staff most closely linked to a particular condition should vet the clinical guidelines incorporated in the query forms as you adapt them to ICD-10-CM/PCS. Many facilities have clinical guidelines to help determine types of congestive heart failure (CHF) based on recent medical literature and as supported by the cardiology department.

The CDI team at [more]

ICD-10 Tip of the Week: Practice makes perfect

Look for all the clinical indicators in the medical record to ensure appropriate sequencing.

Coders are basically going to have to re-learn their jobs. CDI can help.

One of the main pain points CDI specialists stress for ICD-10 preparation is physician education. But what about preparing the coders? After all, it is the code set that’s changing. Coders are basically going to have to re-learn their jobs—they’re going to have to adapt their daily routines to an entirely new, more specific set of codes and rules. The physician could have the most complete and accurate documentation in the world. But if the coder isn’t up-to-speed with ICD-10, all of the physician education will have been for nothing.

As CDI specialists, you can help get coders in tip-top shape for implementation by facilitating and encouraging dual coding practices. If your facility hasn’t begun to do so, start by revising electronic templates and query forms for ICD-10, and revising query policies. From there, encourage coders to begin dual coding to help identify risk areas and coding familiarity. You can start by having coders begin dual coding on a smaller scale, such as high-volume and/or high-dollar DRGs.

After coders [more]

TBT: Getting started with outpatient CDI efforts

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.

Getting started in the outpatient arena requires a few simple steps.

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’re throwing it back to an article from the January 2012 CDI Journal, “Outpatient CDI efforts offer documentation opportunities.”

To start reviews on the outpatient side, conduct a retrospective review of your facility’s top 20 denials for outpatient procedures, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDIS, CCDS, former ACDIS Advisory Board member and independent consultant based in Burlington, Vermont. Then determine what the national coverage determination (NCD) and local coverage determination (LCD) requirements are for those procedures.

Next, [more]