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Q&A: Coronary stent

Go ahead, ask us!

Go ahead, ask us!

Q: The 2016 CDI Pocket Guide states that four or more stents or vessels is equivalent to an MCC and changes the DRG. I understand that Coding Clinic, Second Quarter 2015 defines the number of individual sites instead rather than anatomical vessels. The DRG Expert states four vessels or four plus stents changes the DRG. It was my understanding that when four stents are used in three vessels or sites, the DRG would not change. Could you please clarify if it is the number of stents or the number of sites that changes the DRG?

A: The coronary stent question has plagued the entire coding and CDI community since Oct. 1, 2015. There is much self-contradiction in the DRG titles, which includes vessels and stents, and the meaning of “sites” (implying stent locations) in the ICD-10-PCS Official Guidelines for Coding and Reporting. The Coding Clinic advice published in Second Quarter 2015 helped some, and I believe intended to clarify that the number of coronary arteries treated determines the code assigned, which then drives the DRG.

Because of the confusion and contradictions, the 2017 ICD-10-PCS Official Guidelines for Coding and Reporting sections B3.6, B3.7, B4.4 have been modified to indicate that procedures performed on coronary arteries are classified by the number of arteries treated, not the number of coronary artery sites.  The number of stents does impact code assignment or DRG classification, but the code titles for DRGs 246 and 248 still perplexingly retain “4+ vessels/stents.”

Editor’s note: Richard D. Pinson, MD, FACP, CCS, principal of Pinson & Tang LLC, and author of the CDI Pocket Guide answered this question. Contact him at

Guest Post: Overcome documentation dilemmas for similar procedures

by Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP

Documentation and coding in the outpatient realm can be a challenge. One of the areas that CDI specialists and coders often struggle with is when there are two or more choices for similar procedures. This creates a dilemma, as the documentation and diagnoses attached to those codes can mean a huge difference to the practice, or physician, in terms of reimbursement based upon the relative value unit (RVU) values. In some instances, this could also mean that the choices presented in the CPT Manual may not be well represented. The choices are limited to an unlisted code, then figuring out how to price it for payment and still get the provider fair reimbursement. However, ICD-10-PCS for hospital services is now much more clear-cut and straightforward than CPT codes used for physician-based services.

Consider the following:

History: Patient presents with labial hypertrophy (congenital) and wishes to have a labiaplasty to even up both sides of the labia. Patient reports tearing due to excessive length on the left side, excessive skin gets caught in clothing, and is uncomfortable when sitting for long periods of time, or becomes irritated due to her clothing. Upon examination patient has a class 3 hypertrophy, involving the clitoral hood. ICD-10-CM diagnosis is N90.6 (hypertrophy of vulva; hypertrophy of labia). The physician and patient formally decide to do a labiaplasty as an outpatient procedure. The physician schedules the surgery and performs a labiaplasty.

Procedure: The risks, benefits, indications, and alternatives of the procedure were discussed with the patient and informed consent was signed. The patient was then taken to the procedure room and prepped and draped in the usual sterile fashion. The labia and clitoris were then marked using the marking pen to the patient’s specifications. The perineal area was infiltrated first with the creation of a small bleb followed by infiltration of the labia majora up to the clitoris on the left side. The labia minora was then infiltrated along the lines of demarcation. It was then clamped using Heaney clamps and the tissue excised. The clamped tissue was then cauterized using a single tip Bovie. Excellent hemostasis was confirmed. The clitoral hood was then trimmed using scissors. The exposed tissue of clitoral hood and labia were re-approximated using 3-0 Monoderm. Excellent hemostasis was noted. This completed the procedure. The patient tolerated the procedure and was discharged home in stable condition. Tissue sent to Pathology – no neoplasm noted, no abnormalities noted.

In the above scenario, the CDI specialist is confused regarding which code to use and queries the provider. The physician responds to the query and states CPT code 15839 is the procedure and ICD-10-CM code N90.6 is the diagnosis that should be billed. The physician also responded back to the coder that he did not feel that he performed a “simple vulvectomy” because only a minimal portion of the labia was involved and the tissue that was removed was not diseased or compromised by lesions or other symptoms, as borne out by the pathology report. He stated this was simply a congenital abnormality of one side that was “longer” than the other.

A few weeks later, the coder then has another labiaplasty operative report from the same physician.  However, this one is for a patient who has an ongoing issue with syringoma of the vulva (as borne out by pathology biopsy).

In the following operative scenario, the code 56620 was selected, as this was clearly a disease process:

Operative report: Patient had previous biopsy for syringoma (confirmed). ICD-10-CM diagnosis code is D28.0 (benign neoplasm of vulva). The labia has become enlarged and patient opted for removal as it was becoming bothersome and growing at a rapid rate.

Findings: Three 5 mm intradermal lesions on the patient’s left labia and two 3 mm intradermal lesions on the patient’s right labia majora approximately 2 cm posterior to the clitoris.

Procedure: The patient was taken to the operating room with an IV in place. MAC anesthesia was begun. Patient placed in lithotomy position, prepped and draped. Area was previously identified and marked with marking pen. Two small elliptical incisions approximately 3 cm were made on either side of the lesions. A 15 blade was used to make an incision. The lesions were excised from the underlying tissue. Incisions were sewn back together with running subcuticular stitched with 3-0 vicryl. The patient tolerated the procedure and was discharged home in stable condition. Tissue sent to pathology–confirmed all lesions were denoted as syringoma

This procedure in ICD-10-PCS is much more straightforward, as the code would be 0UBMXZZ (Excision of vulva, external approach). However, with CPT, it is subjective between diseased tissues and normal tissues.

Another coding and billing issue that codes 15839 and 56620 can present is that 15839 has a larger RVU and could be billed as a bilateral procedure, which would have a higher financial reimbursement than 56620, which cannot be billed as a bilateral procedure and has a lower RVU value. Therefore, the CDI specialist must make sure that the code choice for billing is based purely on documentation and physician notation reflected in the operative reports, and not based upon obtaining a higher reimbursement strictly for financial purposes.

Editor’s note:  Webb is an E/M and procedure-based coding, compliance, data charge entry, and HIPAA privacy specialist. She can be reached via email at This article was originally published in JustCoding and the full version can be accessed here. Opinions expressed are that of the author and do not represent HCPro or ACDIS.


Featured Member: CDI takes former nurse overseas

2016-08-09 10.36.33

Jedida Wachira, RN, CDIP

Prior to taking a job as a CDI specialist at United States Navy Hospital in Okinawa, Japan, Jedida Wachira, RN, CDIP, worked for a company that experienced a major Medicare audit. Everyone was in a frenzy about documentation, she says. As a nurse working on the floor, she’d always focused on quality patient care, and never paid much attention to reimbursement, or how quality tied into the revenue cycle.

“On the floor, all I needed to know was that [my patient supplies] would be where I needed them,” she says. “The profound penalties the company faced prompted me to look into the documentation side of the medical field.”

One thing stuck with Wachira from her Medicare audit experience—her interest in improving clinical documentation, where she’s worked for nearly six years.

Married to her high school sweetheart, Wachira and her husband have three boys—one on high school, one in elementary school, and one still in diapers. She enjoys spending quality time with her family and relaxing.

ACDIS Blog: What did you do before entering CDI?

Wachira: My last floor nursing job was for a local hospice house, where I worked for more than three years. While I was working on the floor, I assisted coordination of care and documentation for change in level of care as well. It was incredibly rewarding to provide this direct clinical and emotional support to these patients.

ACDIS Blog: What has been your biggest challenge?

Wachira: My biggest challenge was learning all the coding guidelines, conventions, and DRG concepts. I was so happy when I started to master some of the ICD-9 codes—and then the transition to ICD-10 occurred! Keeping up with the constant code changes and regulations is always a challenge for me.

ACDIS Blog: What has been your biggest reward?

Wachira: The leaps and bounds in knowledge that I have acquired and continue to acquire and pass on to others. The ability to discuss cases with physicians and learn, as well as teach, is great. I have started two programs and educated staff members that had no knowledge of coding, DRGs, severity of illness/risk of mortality, or case mix index. To see staff as they begin to understand the bigger picture and change their documentation habits is so rewarding.

ACDIS Blog: Why did you join ACDIS?

Wachira: It simply makes sense to have a forum that allows fellow CDI specialist to discuss and share knowledge. One can never truly know it all in this field—there is always room for networking and learning from each other.

ACDIS Blog: What piece of advice would you offer a new CDI specialist?  

Wachira: Stick with it, don’t give up, give yourself time to learn the concepts, and allow yourself room for error. Don’t expect that you will know everything about coding and records review from the beginning. Expect to make a coding error every now and then and, when you do, learn from it and move on.

ACDIS Blog: Tell us a few of your favorite things?

Vacation Spots: Anywhere with a beautiful beach and clear water.

Hobbies: Reading and watching movies with the family.

Favorite non-alcoholic beverage: Coconut and passion juice over pistachio flavored ice-cream.

Favorite food: Anything my husband makes—yes I know it’s cliché, but he is a really good cook!

Favorite activity: Lounging on the couch with the family. Nothing beats those moments of love, where we get to spend time together.


A Note from ACDIS: Make the most of your membership

What's your top 10 common CDI specialist idioms?

Take full advantage of your member benefits.

ACDIS hit a number of milestones in the last year—5,000 members, 3,400 CCDS holders, nearly 2,000 conference attendees. While we’re excited to see our numbers grow, every now and then, we’re contacted by a member unaware of the resources available to them. We want you to be able to make the most of your ACDIS membership. Here’s how you can take full advantage of your member benefits.

Read the CDI Journal: The bi-monthly, electronic CDI Journal offers members timely, in-depth news and regulatory information, clinical tips and analysis, case studies, and membership profiles. Whether you’re looking for advice on building a successful CDI program or expanding into outpatient or pediatrics, the journal offers a wide range of information to keep you abreast of industry trends and advances.

By reading the CDI Journal, CCDS holders may also obtain one continuing education credit. To obtain the credit, you must complete and pass the online quiz. Click here to access. Your certificate will be automatically emailed to you upon successful completion of the quiz.

Join the ACDIS Forum: Formerly known as CDI Talk, the new ACDIS Forum allows members to connect with and ask questions of their CDI colleagues from across the country. From expansion to management to pediatrics, the distinct categories make it easy to pose questions and peruse discussions.

New to the Forum? Many of our CDI Talkers loved that they could set up notification emails with new conversations and responses on the old website. The new Forum offers this feature too—click here for instructions.

Participate in quarterly networking calls: Members have the unique opportunity to participate inquarterly membership conference calls, an hour-long discussion and open Q&A with the ACDIS Advisory Board. These calls cover all things CDI, including top trends and current concerns in the industry. Members are e-mailed dial-in information the week prior to the event. Questions can be submitted ahead of time by e-mailing Melissa Varnavas at The next quarterly call, sponsored by Optum360, is scheduled for today, Thursday, August 18 at 1 p.m., eastern. All quarterly calls are recorded and available to members on the ACDIS site. Click here to access.

Access helpful resources:

The electronic ACDIS Resource Library houses a myriad of sample queries, policies, and other tools, available exclusively to members. In addition to forms and tools, the library also houses peer-reviewed position papers, white papers, and surveys.

Post to our career center:

The new ACDIS Career Center allows you to upload your resume anonymously, browse open positions, and sign up for alerts about new jobs specific to your criteria. If you’re looking to hire, we have job posting options as well as the ability to browse our resume database. ACDIS members receive two free job postings a year as well as discounted additional posts. Click here to learn more.

And more…:

In addition to the numerus tools, resources, and opportunities, ACDIS members also receive discounts to the annual ACDIS conference, CCDS certification, and CDI Boot Camps. Members are also able to participate in an Official ACDIS Local Chapter, under the leadership of the Chapter Advisory Board.

Not a member?

Even if you aren’t currently an ACDIS member, we offer free content via our weekly e-newsletter, CDI Strategies, and the daily ACDIS Blog. Stay up-to-date with current news, trends, and tips without spending a dime. Remember, non-members must register to access free content—click here to set up your username and password.

Local Chapter Update: Georgia ACDIS chapter discusses evolution of CDI

Don't miss a chance to network with CDI from your state!

Don’t miss a chance to network with CDI from your state!

The Georgia ACDIS Chapter successfully wrapped up its day-long event last Friday, August 12, at the Tift Regional Medical Center in Tifton. The agenda was jam-packed with sessions covering just about every hot topic in CDI, but the key takeaway, according to chapter leader Julie Bell, is that the role of the CDI specialist is changing, quickly.

After a networking breakfast and brief welcome message from the event organizers, Mindy McStott, BSN, MSW, CCM, VP of Quality at Tift Regional, discussed the relationship between CDI and quality, and how CDI can effectively collaborate to ensure accurate documentation of quality-based measures. “This changes CDI from your basic CC/MCC capture to pay-for-performance, bundled payments, core measures, and things like that,” said Bell.

The meeting attracted a number of vendors, including Chartwise, 3M, and ModusOne Health. Each offered unique sessions on the changing CDI roles, denials management, and advancing into outpatient documentation reviews.

John Crongeyer, MD, JD, co-founder and CEO, ModusOne Health discussed the role of CDI in avoiding lawsuits, focusing on provider relationships. CDI specialists need to understand the physician’s knowledge base, and their need for firm clinical criteria to make a diagnosis.

“Physicians need clinical evidence to make a diagnosis,” said Bell. “The session included a sepsis example, where the provider could see that the patient was septic, but couldn’t speak to why they felt that way. We need hard and firm criteria to allow them to make that diagnosis.”

The event wrapped up with an emerging topic for CDI professionals—outpatient documentation improvement. 3M took the stage and discussed the process of expanding into outpatient record reviews through case examples.

The focus of all local chapter events is to provide education and, of course, networking. Attendees were able to connect with colleagues and vendors throughout the day at a networking lunch and break.

“It was wonderful to see the collaboration and interaction,” says Bell. “Networking is what keeps the chapter going, and allows us to connect with speakers, new members, and identify topics for education.”

Editor’s note: Find a local chapter event near you for networking, education, and more. Click here to view a list of upcoming meetings.

From the Forum: Hydrocephalus—to code or not to code?

Open dialogue is the most valuable tool we have to grow the CDI profession.

Join the discussion on the ACDIS Forum at

Hydrocephalus is coded a few different ways across pediatric facilities, according to a recent post on the ACDIS Forum. But at USA Children’s & Women’s Hospital in Mobile, Alabama, they’re being told not to code the condition at all in patients who have a ventriculoperitoneal (VP) shunt procedure, says Jeff Morris, RN, BSN, CCDS, a CDI specialist at the facility. This is because the procedure resolves the hydrocephalus, meaning the hydrocephalus is not present anymore, he says.

Congenital malformations that have been corrected should be coded as a “history of,” Morris says, but that doesn’t necessarily mean the hydrocephalus has been corrected. If the catheter kinks or malfunctions, then the hydrocephalus can cause issues and revisions and/or replacements must be made, he says. Nevertheless, the CDI team was advised to code the VP shunt status only.

This issue is similar to coding conditions like pediatric asthma, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF)—even when treated, the condition doesn’t simply “go away,” and, typically, they continue to monitor the patient. So, how do can/should similar cases get coded?

Hydrocephalus can be captured as a secondary diagnosis, says Claudine Hutchinson, RN, CDI specialist at The Children’s Hospital at Saint Francis in Tulsa, Oklahoma.

VP shunting redirects the fluid away from the brain to other anatomical sites, relieving pressure, but does not ‘cure’ the hydrocephalus, says Paul Evans, RHIA, CCDS, CCS, CCS-P, Clinical Documentation Integrity Leader at Sutter West Bay Area in San Francisco. Evans suggests searching related medical sites to determine if this is the “prevailing philosophy” of subject matter experts on this condition.

“I code the hydrocephalus, as it is my feeling that it is not cured, but is being managed with this device,” says Evans. “At the very least, if a VP shunt is present, examine any radiological studies that demonstrate support for the condition before making a blanket decision that the presence of VP means one can ‘never’ code the disease.”

In comparison, say a patient receives a slow pathway (S/P) ablation of the sinoatrial node for atrial fibrillation (a-fib), and continues to experience a-fib after the procedure. “The a-fib is not cured,” says Evans, in response to this scenario by the American Hospital Association. Applying this logic to a patient with an S/P shunt for hydrocephalus would result in coding the diagnosis Hydrocephalus, Obstructive, according to Evans.

Coding Clinic, Fourth Quarter, 1993 states:

Question: The patient is a 48-year-old woman with a history of acquired aqueductal stenosis and ventriculoperitoneal (VP) shunt status since age fifteen with multiple revisions. She was transferred to the LTCH with residual focal neurological deficit and left-sided weakness, following shunt revision during acute care stay. The patient also received IV antibiotics for postoperative Staphylococcus aureus wound infection, and external surgical wound dehiscence. The physician felt that the residual focal neurological deficit could be rehabilitated and the patient was admitted to the long term care hospital specifically for rehabilitative services (i.e., physical and occupational therapy) with ongoing conditioning. How should this be coded?

Answer: Assign code V57.89, Other specified rehabilitation procedure, as the principal diagnosis. Since the patient was admitted to the long term care hospital specifically for rehabilitative services, code V57.89 is appropriately assigned as the principal diagnosis. Codes 998.32, Disruption of external operation wound, 331.4 Obstructive hydrocephalus, 998.59, Other Postoperative infection, 041.11, Staphylococcus aureus, V09.0, Infection with microorganisms resistant to penicillin, and V45.2, Presence of cerebrospinal fluid drainage device, should be assigned as additional diagnoses. Assign codes 93.39, Other physical therapy and 93.83, Occupational therapy, for the therapy provided.

In short—if the documentation states that a condition was treated, it does not mean the condition was cured or, further, is irrelevant to the episode of care.

Editor’s note: This content was taken from a recent discussion on the new ACDIS Forum. To participate in this discussion, or other discussions available on the forum, click here.


Guest Post: AHIMA addresses clinical validation, coders and CDI defining diagnoses

James Kennedy, MD, will present a two-day preconference regarding the role and responsibilities of physican advisors for CDI.

James Kennedy, MD

by James Kennedy, MD, CCS, CDIP

AHIMA recently published a clinical validation practice brief in the July 2016 Journal of the American Health Information Management Association, available to AHIMA members on their website. In it, they state:

Although it is tempting for CDI and coding professionals to define diagnoses for providers, doing so is beyond their scope. For example, it is not appropriate for a CDI or coding professional to omit the diagnosis of malnutrition when it is based on the patient’s pre-albumin level rather than American Society for Parenteral and Enteral Nutrition (ASPEN) criteria. Many practicing physicians have not adopted ASPEN criteria and there is no federal or American Medical Association (AMA) requirement stating that ASPEN criteria must be utilized by a physician in making the diagnosis of malnutrition.

While this is technically true, given that CDI and coding professionals are not licensed to practice medicine, nor are involved with direct patient care under most circumstances, they still should be their facility’s representatives to encourage the medical staff, as a whole, to adopt facility-wide definitions of challenging clinical terms (e.g., sepsis, malnutrition, acute respiratory failure). They should also monitor and encourage individual providers as they adopt these definitions in their documentation and escalate noncompliance with these definitions to physician advisors, compliance officers, or medical staff leadership.

While one physician may not use ASPEN, or the Academy of Nutrition and Dietetics criteria, to define and diagnose malnutrition, I challenge readers to find any support for pre-albumin or albumin as a current clinical indicator for malnutrition, or more authoritative criteria than that of the nation’s premier association of dieticians and nutritional support teams.

Multiple choice queries

AHIMA appears to have changed the language for multiple choice queries with this practice brief, especially when clinical validity is an issue (something it supported in its 2013 Guidelines for Compliant Query Practices, jointly authored with ACDIS). In its recent policy brief, AHIMA offered an example for validating documented sepsis without apparent clinical indicators, they offered the following multiple choice options:

  • Sepsis was confirmed
  • Sepsis was ruled out
  • Sepsis was without clinical significance
  • Unable to determine
  • Other ______________

Given that this is AHIMA’s query format, we’re obligated to consider it; however, this does cause some difficulties. What can a coder do with “sepsis was without clinical significance” or “unable to determine,” if that’s the option the provider selects? If “sepsis was without clinical significance” is selected, do we not code it with the belief that the documented condition doesn’t qualify as an additional diagnosis as defined in the ICD-10-CM guidelines? How many of us have run into physicians who document “unable to determine” as a way of avoiding the question?

I believe that if any of these two options are chosen, then the record should be escalated to a physician advisor or coding manager who implements the facility’s policy of coding the documented diagnosis without defendable clinical indicators.

Editor’s Note: This article originally appeared in JustCoding. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at Opinions expressed are that of the author and do not represent HCPro or ACDIS.

A Note from the ACDIS Director: Interested in “advancing CDI?” Apply to speak at the 2017 ACDIS conference

ACDIS Director, Brian Murphy

ACDIS Director, Brian Murphy

by Brian Murphy, CPC

On Friday, we opened up our speaking applications for the 2017 ACDIS conference.  Our 2017 program, which takes place May 9-12, at the MGM Grand in Las Vegas, marks the 10th annual ACDIS conference. We hope you can join us, and we’d love to have you share your ideas, insight, and expertise on the podium!

Speaking at ACDIS has many benefits, including:

  • Personal and hospital recognition. You’ll be visibly sharing your ideas and have a great addition to your resume and portfolio of accomplishments
  • Additional CEU opportunities. Earn credits towards your CCDS (two CEUs for each half-hour of presentation time)
  • Free admission to the conference for you and your co-presenters

Our 2017 ACDIS Conference Committee compiled a “must-have” list of recommended sessions to help you shape your submission. But if you don’t see your idea listed, that’s just fine: We also welcome creative, out-of-the-box applications as well.

The ACDIS conference offers basic sessions for profession newcomers, as well as sessions for those at an intermediate and advanced levels. This year the committee particularly wants enough advanced sessions on the podium to satisfy those with 8-10 years (or more) experience in the CDI profession. While we are accepting sessions at any level, advanced sessions will be given additional consideration by the committee. How are we defining “advanced,” you ask? It’s as follows:

Advanced CDI sessions are those that include information that benefit established CDI programs and the experienced CDI professional. This content includes statistics and data obtained after implementation and evaluation of new and advanced processes, second level review, collaboration with ancillary departments, identification of query opportunities beyond CC/MCC capture, and advanced management processes. Advanced coding/clinical sessions should include complex case examples.

The speaker application period closes Monday, September 12. Speaker selection will be made by the Conference Committee and applicants will be notified of their decision in late October/early November.

In short, attend the conference and please apply to speak—sharing ideas and celebrating success are what ACDIS community and networking are all about.

Note: To get a better idea of the energy and information sharing that goes on at this one of a kind CDI event, please take a look at our 2017 promotional video here, shot onsite at the 2016 conference.

Radio Recap: The role of CDI in risk-adjustment

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.

As the healthcare industry shifts from traditional fee-for-service to a value-based and quality-driven model, CDI specialists should be aware of the principles that drive risk adjustment payments. “I describe it as traveling down parallel to that which we travel to establish the DRG,” says Laurie Prescott, MSN, RN, CCDS, CDIP, CRC, CDI Educational Director for ACDIS and BLR Healthcare in Middleton, Massachusetts, during theAugust 10 ACDIS Radio program.

Patients bring their own medical complexity, and CDI specialists must make sure that the documentation captures those complexities. Each patient has their own level of risk, Prescott says, which includes the severity of illness and expected cost to manage their care needs.

For example, take an 85-year-old woman who lives at home, participates in aerobic dance and yoga twice a week, is a non-smoker, and her only comorbidity is osteoporosis. This patient will have a very different rating in risk adjustment than an 87-year-old who lives in a skilled nursing facility, is diabetic, has a history of stage 4 chronic kidney disease, and chronic obstructive pulmonary disease with a history of smoking. This higher risk adjustment score reflects the higher cost of care we are expected to expend due to the higher severity of illness.

Many quality measures included in CMS’ hospital value-based purchasing program are risk-adjusted, including 30-day mortality and 30-day readmissions, says Prescott. “We want to make sure that we’re capturing [documentation] for risk adjustment, which is very different methodology.”

The most common methodology used in risk-adjustment is the CMS Hierarchical Condition Categories (HCCs), says Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, CRC, director of HIM/Coding for BLR Healthcare. HCCs share many similarities to the DRG system CDI specialists are used to working with. Both are prospective systems, meaning there are pre-determined payments for different diagnoses, and both use diagnostic information to drive either the overall assigned DRG or HCC. However, HCCs are cumulative in nature—all you need is one heavily-weighted diagnosis to boost the DRG for a singular inpatient admission, but, with HCCs, diagnoses are extrapolated for many encounters for that beneficiary for a time period (e.g. year) that contribute to the total patient risk score. Procedures don’t affect HCCs like they can for DRGs, says McCall. HCCs are solely diagnosis-driven, an ideal fit for CDI specialists who typically focus on diagnoses for documentation improvement.

Chronic conditions for risk-adjustment have a much bigger role in HCCs than DRGs, where most chronic conditions have little impact on reimbursement, says McCall. Take heart failure, for example. In the MS-DRG system, the CDI specialist may find an opportunity to query for added specificity for systolic or diastolic, as well as acuity to optimize the DRG. However, for risk adjustment, the documentation of heart failure in the record yields a HCC even without the additional specificity.

The common misconception is that HCCs apply to the outpatient setting only. This is not the case, according to McCall. Documentation to support a condition assigned to an HCC can come from outpatient, inpatient, and professional service documentation. Payers look at documentation from every setting for the reporting period for each beneficiary to determine whether a diagnosis should have been reported and is supported in the documentation.

“CDI specialists have to get used to looking at the record as a whole,” says McCall.

While conditions count toward a patient’s HCCs regardless of treatment setting, documentation and coding specialists need to follow the coding rules applicable to the setting in which the patient was treated and services were provided. Depending on the setting (outpatient or inpatient), documentation requirements for certain diagnoses in the HCC methodology will differ.

“From a rules standpoint, coding guidelines differ depending on setting and services,” says McCall. “CDI specialists need to be familiar with what diagnoses were documented, what setting they were provided in, and then apply the coding and documentation rules for that setting.”

For facilities looking to expand into risk-adjustment, Prescott says first identify which diagnoses “will map” to HCCs. Go to the website to find comprehensive HCC information, including lists of codes and how each maps to which HCC and its value. While self-study may seem intimidating, it is a great first step, Prescott said.

“Traditionally, the main focus of CDI is principal diagnoses and sequencing correctly,” says Prescott. “In HCCs, sequencing isn’t something we worry about.  We want to capture all of the appropriate diagnoses, and review records for missing or vague diagnoses. This is what CDI has been doing all along.”

Conference Update: Join us on the podium at the 2017 ACDIS conference!

Apply to speak at the ACDIS Conference!

Apply to speak at the ACDIS Conference!

The Association of Clinical Documentation Improvement Specialists (ACDIS) is currently seeking speakers to present at the 2017 ACDIS ninth Annual Conference, to be held May 9-12, 2017 at the MGM Grand in Las Vegas, NV. Click here to view and complete the speaker application.

Is that special person you or a colleague?

We seek speakers to present on all aspects of clinical documentation improvement (CDI). Advanced CDI sessions geared for mature programs are particularly welcomed and will receive additional consideration*. CDI and/or HIM/coding professionals typically present at ACDIS, but we also welcome practicing physicians, case management and quality personnel, healthcare auditors, lawyers, and other professionals with a tie to or an interest in CDI. Accepted speakers and co-presenters will have their admission fee waived.

Based on the learning needs identified by participants of the successful 2016 ACDIS Conference, several topics have emerged as areas of great interest within the ACDIS community. We are seeking potential speakers and panels for the 2017 ACDIS conference for the following tracks and sessions:

Track 1: Clinical and coding

Proposed breakout sessions:

  • Physician/clinically driven sessions on pathophysiology and diagnostic criteria (clinicians welcomed)
  • Coding Clinic and Official Coding Guidelines updates
  • Surgical procedures (CDI/coder with surgeon co-presenters welcomed), emphasis on ICD-10-PCS and root operations
  • Coding and clinical criteria of complex and/or lesser reported diagnoses (i.e., functional quadriplegia, ATN vs. AKI, hypertensive heart disease, sepsis, types of respiratory failure, encephalopathy, traumas, malnutrition, HCAP/CAP, etc.)
  • Advanced chart review techniques, including interpreting subtle clinical indicators, lab values, etc.
  • Complications of surgery vs. inherent to procedure
  • Dealing with unsupported diagnoses in the medical record
  • Presentation of specific documentation requirements to support code assignment by diagnosis
  • Presentation of complex coding (ICD-10) case studies
  • Impact of ICD-10 post-implementation
  • Sepsis: Management of definitions

Track 2: Management and leadership

Proposed breakout sessions:

  • Metrics: Selecting metrics to measure individual CDIs and CDI departments, analysis and interpretation of data
  • Proving/presenting CDI return on investment data
  • Auditing CDI staff: How to audit, how often, and follow-up/training using audit findings
  • Managing CDI staff: Setting productivity expectations, rewarding high performers, managing underperforming CDI specialists
  • Training and orienting CDI staff, establishing career ladders, motivating senior CDI staff, providing continuing education
  • Remote CDI: Management and operational issues
  • Productivity: Setting standards, monitoring performance
  • Electronic health records (EHR) management, including battling note bloat and copy/paste, managing problem lists, improving EHR CDI/physician documentation functionality through working with vendors, pros/cons of computer assisted coding and natural language processing, etc.
  • Engaging physicians in CDI: initial buy-in and education, ongoing training, tips for working confidently and effectively with providers
  • Managing CDI in a regional/multi-hospital system
  • Principles of effective leadership and department management

Track 3: Quality and regulatory

Proposed breakout sessions:

  • IPPS and CMS regulations—critical updates and what they mean for CDI professionals
  • APR-DRGs/severity of illness and risk of mortality, including diagnoses that affect SOI/ROM but not reimbursement
  • Reviewing for Patient Safety Indicators (PSI), PSI 90 nuances and updates
  • Reviewing for Hospital Acquired Conditions, Hospital Acquired Infections, Present on Admission indicator
  • Partnering with quality department
  • Hospital Value Based Purchasing and the role of CDI professionals
  • Hospital Readmission Reduction Program
  • Utilization review and CDI (2 Midnight Rule, medical necessity reviews, )
  • Bundled payment initiatives and how CDI can make an impact
  • MACRA and physician payment reforms—overview and leveraging to improve physician buy-in
  • Mortality/retrospective reviews, CDI involvement in mortality conferences
  • Compliance initiatives and ethics in CDI
  • Accountable Care Organizations and the role of CDI

Track 4: CDI Expansion

Proposed breakout sessions:

  • Outpatient CDI: All aspects including case studies of successful programs, starting/implementing/staffing an outpatient CDI program, defining payment models and metrics for success, sample outpatient queries and review strategies
  • Medicare Advantage/HCCs and medical record review strategies
  • Next steps/growth areas for advanced CDI departments
  • Incorporating core measures (i.e., CMS Quality Measures) into CDI review
  • Physician advisor specific sessions
  • Recovery Auditor and up-front denials prevention
  • CDI assisting with back-end denials management/appeals
  • Query escalation policies and real-world examples
  • Clinical validation: Examples and process, auditor denials, as well as appeals and prevention

Track 5: Innovative CDI

Proposed breakout sessions:

  • Pediatric CDI, including advanced sessions on SOI/ROM impact, outpatient pediatric CDI, pathophysiology sessions unique to pediatric patients including heart failure, acute respiratory failure, sepsis definition, etc., ongoing measurement of pediatric CDI programs, pediatric research and quality improvement projects
  • CDI in maternity, pregnancy, post-partum, NICU, OB/GYN
  • Challenges of available NICU codes
  • Educating residents and med students in documentation
  • CDI in post-acute settings, including Long Term Acute Care (LTAC) and inpatient rehab
  • Inpatient psychiatry
  • CDI in critical access hospitals
  • CDI in the physician office setting
  • Development of specialized CDI roles
  • CDI and concurrent coding
  • Healthgrades, Leapfrog, Hospital Compare, etc.—a review of publically available rankings/scorecards, how CDI can impact and use them to promote physician buy-in
  • Next level of CDI metrics beyond CMI and CC/MCC capture
  • Presentation of CDI research projects or findings

If you don’t see your hot topic listed here, please write and let us know what expertise you can bring to the podium. Original ideas are welcomed. Although we are looking for advanced level sessions, the ACDIS conference includes basic, intermediate, and advanced sessions to accommodate attendees at all levels. Please find your topic and level of choice and apply!

*Advanced CDI sessions are those that include information that benefit established CDI programs and experienced CDS’. This content includes statistics and data obtained after implementation and evaluation of new and advanced processes, second level review, collaboration with ancillary departments, identification of query opportunities beyond MCC/CC capture, and advanced management processes. Advanced coding/clinical sessions should include complex case examples.

Application instructions

Click here to view and complete the speaker application. We recommend you copy/paste into the fields from a word document. The speaker application period closes EOD Monday, September 12. All final decisions will be made by the 2017 ACDIS conference committee and applicants will be notified of their decision in late October/early November.