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A Note from the Associate Editorial Director: Growing the CDI profession

Melissa Varnavas

Melissa Varnavas

As you read this, the ACDIS administrative team may likely be ensconced in a conference room examining data from its members and discussing plans for products and services for the coming months.

A good piece of that data comes from a membership survey earlier this year in which members offered their thoughts about their daily challenges and association offerings.  Regarding challenges CDI professionals face, physician engagement, education, and pushback (lack of buy-in and support for documentation improvement efforts) topped the list at numbers one, two, and three of the top 10. The next problematic grouping stemmed from CDI staffing with retention, recruitment, and training tagged as trouble spots. The final group essentially focused on CDI program management concerns such as proving return on investment, setting productivity and quality benchmarks, meeting the challenges of growing and evolving expectations.

Although we can’t be in the halls with you talking to physicians, persuading administrators, and helping your CDI staff learn the ropes, we’re with you in spirit, with you in community. More than 73% of respondents to the survey have been ACDIS members 1-6 years and 56% say they come to the ACDIS site at least once a week or more frequently with some coming to the site multiple times per day.

Members indicated that they value the CDI Journal, Forms & Tools Library, this email newsletter, and the Quarterly Conference Calls most. It doesn’t surprise me (although it’s great to hear) how much these tools are appreciated given the challenges faced in the industry today.

We often discuss the exact challenges described within the pages of the Journal, during the Advisory Board Members’ Quarterly Conference Call, and in the email dialogue of CDI Talk. We often share sample PowerPoint presentations, tip cards, and physician education items in the Forms & Tools Library and the forthcoming (May 2016) edition of the Journal delves into a variety of methods to help improve physician support.

One respondent said she reads the Journal the moment its posted and called the bi-monthly publication “awesome.” Another respondent said the Forms & Tools Library is her “go-to” spot on the site and loves the fact that the community “all shares our best practices and documents.”

Healthcare changes rapidly (look no further than the Sepsis-3 clinical guidelines released last month) as do the rules and regulations governing payment for that care (read the article about MS-DRG changes in today’s edition) and CDI specialists need a trusted resource to get the latest information, distilled in a manner that identifies the most pertinent information for the profession.

I’m looking forward to today’s meeting. We have an amazing story to tell and tremendous opportunities to continue to help grow this profession.

Weekend Reading: The case mix index

Everyone is catching up on their weekend CDI reading!

Everyone is catching up on their weekend CDI reading!

The case mix index (CMI) is a common metric used to evaluate the return on investment (ROI) from a CDI department. However, it is a very broad metric that is affected by more than just CDI efforts. In its simplest form, the CMI represents the complexity of the patient population, which, in turn, represents revenue.

Each MS-DRG has an associated relative weight (RW), the factor upon which an organization’s payment is based. CMS introduced the concept of severity within their DRG methodology beginning in 2008, when secondary diagnoses could be classified as either a CC or MCC. Therefore, the RW of an MS-DRG where an MCC is captured is significantly higher than the relative weight of an MS-DRG without a CC or MCC. This is why CMI (i.e., the average RW for a population over a period of time) is often used to measure the success of a CDI department. The assumption is a CDI specialist will increase the volume of cases where a CC or MCC is reported, resulting in reporting claims with a higher RW, ultimately resulting in a higher CMI.

Although CDI efforts can positively affect CMI, the CDI department’s success can only be accurately represented if all other variables remain constant. Since the RW also varies by type of MS-DRG (i.e., medical vs. surgical), an organization that performs a high volume of surgeries will have a higher CMI compared to an organization that doesn’t perform many surgeries. The type of surgeries performed also affects CMI. For example, organ transplants are very complex surgeries, so they are associated with a very high RW. As another example, depending on the size of the organization, if all the cardiothoracic surgeons attend a conference for a week, say, the organization’s CMI would likely drop due to the loss of those surgical claims.

Editor’s Note: This excerpt comes from the recently published book, The Complete Guide to CDI Management, by Cheryl Ericson, MS, RN, CCDS, CDIP, Stephanie Hawley, RN, BSN, ACM, and Anny Pang Yuen, RHIA, CCS, CCDS, CDIP. For additional information see these related articles:

Guest Post: ICD-10 changes included in IPPS proposal

Nancy and Benjamin

Nancy Cervi, RHIT, CCDS, and her pet puppy Benjamin.

By Nancy Cervi, RHIT, CCDS

On April 19, 2016 CMS posted the proposed IPPS update for fiscal year (FY) 2017 (effective October 1, 2016). Below is just a highlight of some of the coding/grouping changes.


Table 6A:   1,900 Proposed New Diagnosis Codes
Table 6B:   3,645 Proposed New Procedure Codes
Table 6C:   305 Deleted Diagnosis Codes
Table 6I.1:  82 Proposed Additions to the MCC List
Table 6I.2:  13 Proposed Deletions to the MCC List
Table 6J.1:  326 Proposed Additions to the CC List
Table 6J.2:  65 Proposed Deletions to the CC List

CMS link:

Table 6E:-Revised Diagnosis Code Titles for this proposed rule refer to a document containing the FY 2017 revised diagnosis code titles, as well as new diagnosis codes that have been finalized to date since implementation of the partial code freeze. This was made available in advance in response to requests from the health care industry.  Refer to:

This will bring the total number of ICD-10 codes as follows:

                             Proposed Total FY 2017
ICD-10-CM  71,558                 ICD-10 PCS  75,625

This proposed rule contains quite a few grouping changes in many areas due to replication issues reported in disparity between ICD-9 grouping and ICD-10 grouping. As a result, there are proposals to add multiple diagnosis and procedure codes to the major diagnostic categories (MDCs) for FY 2017. These changes are reflected in the proposed rule document as well as in Table 6.  Some of these areas are:

  • Pacemaker Procedures Code Combinations Methodology
  • Reassignment of Endovascular Thrombectomy of Lower Limbs
  • Transcatheter Mitral Valve Repair with Implant (proposal to collapse MS-DRGs 228, 229, and 230 from three severity levels to two severity levels by deleting MS-DRG 230 and revising MS-DRG 229.
  • Excision of Ileum and Jejunum (Reassigned to MS-DRGs 329-331)
  • Bypass Procedures of the Veins (Bypass Portal Vein to Lower Vein to MDC 5)
  • Removal and Replacement of Knee Joints (New Code Combinations to capture removal of a spacer and insertion of a new knee joint prosthesis)
  • Decompression Laminectomy (Reassign to MS-DRGs 028-030, 518-530)
  • Diagnosis of Lordosis moving from the secondary diagnosis list to logic for principal diagnosis list.
  • Pelvic Evisceration movement from code cluster for MDC 6 to MDC 13.
  • Angioplasty with open approach (Add to Grouping for MS-DRGs 047-039)
  • Excision of Abdominal Arteries
  • Excision of Retroperitoneal Tissue (Add to MS-DRGs 356-358)
  • Occlusion of Vessels (Esophageal Varices and Occlusion of Esophageal Vein))
  • Excision of Vulva, External approach (Add code 0UBMXZZ to MS-DRGs 746, 747)
  • Lymph Node Biopsy (Thorax)
  • Obstetrical Laceration Repair (Adding procedure codes to MS-DRG 774)
  • Operations on Products of Conception (adding procedure codes to correct fetal defects)
  • Other Heart Revascularization (Bypass procedures MS-DRG 228, 228)
  • Procedures on Vascular Bodies: Chemoreceptors
  • Repair of the Intestine (Add Codes for Large intestine and Colon)
  • Insertion of Infusion Pump/Device
  • Procedures on the Bursa (Division of Wrist Bursa and Ligament)
  • Procedures on the Breast (Repair, external approach)
  • Excision of Subcutaneous Tissue and Fascia
  • Should Replacement (Humeral Head with Synthetic Substitute)
  • Reposition (Vertebrae)
  • Bladder Neck Repair
  • R. Procedures to Non-O.R. Procedures (See Table 6)
  • Non-O.R. Procedures to O.R. Procedures (See Table 6)

Also in the proposed rule, we find the Medicare Code Editor (MCE) changes for age conflict, sex conflict, non-covered procedures edit, unacceptable principal diagnosis edit (removing diagnosis codes for live born infant born outside the hospital. (Z38.1, Z38.4, Z38.7). Be sure to review this section for other MCE changes as well.

Lastly, there were nine proposals for New Services & Technology Add-on Payment Proposals:

  1. MAGEC® Spinal Bracing and Distraction System (MAGEC® Spine)
  2. MIRODERM Biologic Wound Matrix (MIRODERM)
  3. Idarucizumab
  4. Titan Spine (Titan Spine Endoskeleton® nanoLOCK™ Interbody Device)
  5. Andexanet Alfa
  6. Defitelio® (Defibrotide)
  7. EDWARDS INTUITY Elite™ Valve System
  8. GORE® EXCLUDER® Iliac Branch Endoprosthesis (IBE)
  9. Vistogard™ (Uridine Triacetate)

Comments must be received by June 17, 2016.  You may (and are encouraged) to submit electronic comments on this regulation to: Follow the instructions under the “submit a comment” tab.

Editor’s note: Nancy Cervi, RHIT, CCDS, is Senior Member in Clinical Documentation for Nuance Communications Healthcare Division,  responsible for HIM Content Development with the Clintegrity Coding and Compliance product.

News: National agency changes terminology associated with pressure ulcers

Sharme Brodie

Sharme Brodie

By Sharme Brodie, RN, CCDS

It seems change lurks near every corner we turn this year. While not every change results in significant shifts in CDI or coding practices, many still require our attention. In that regard, the National Pressure Ulcer Advisory Panel (NPUAP) announced two changes in the description of pressure ulcers recently.

The first, and relatively minor, change is a shift from Roman to Arabic numbers to identify the pressure wound stages to describe the extent or depth of the wound. Otherwise, the wound descriptions of stages 1-4, unstageable, and deep tissue injury, have not changed and are consistent with the ICD-10-CM code set. (For further information, related to the staging and wound descriptions visit

The second, and potentially more problematic, change regards NPUAP’s shift from the term “pressure ulcer” to the term “pressure injury” to more accurately describe damage to both intact and ulcerated skin. It describes a pressure injury as localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical device. The injury can present as intact skin or an open ulcer. These injuries result from intense and/or prolonged pressure or pressure combined with shear.

One reason behind the change is to alleviate the confusion between a stage 1 and deep tissue injury which are both used to describe an injury of intact skin, while the other stages describe open ulcers to the skin.

The term “suspected” has also been removed from the title of deep tissue injury.

ICD-10-CM includes phrases such as bed sore, decubitus ulcer, plaster ulcer, pressure area, and pressure sore as inclusion terms, meaning documentation of these terms will allow for the assignment of a code from the L89 code group for pressure ulcer. The term “pressure injury,” however is not listed.

The NPUAP is viewed as the leading authority related to pressure ulcer prevention and treatment. This panel provides education and research related to improved outcomes and prevention of pressure ulcers. Therefore, CDI professionals will likely soon begin to see providers using the term “pressure injury” in their documentation. The question is how will such documentation affect code assignment since there is no diagnosis code for “pressure injury.”

As CDI professionals we must now work with the issue that the expected professional terminology does not match the wording within the code set. This is much like how we struggled with the professional descriptions related to systolic and diastolic heart failure versus the more recent terminology of reduced or preserved ejection fraction. When providers use terms that were not evident within the code set we have to query for the needed specification. Fortunately, after a number of years a change was made with the most recent AHA Coding Clinic that allows more flexibility related to the coding of heart failure.

In a communication with ACDIS Director Brian Murphy, NPUAP’s Director of Meetings and Operations Jen Bank indicated that OASIS and CMS were notified of the change, stating, “This information is now in their hands, and as I’m sure you know it can take a while for government organizations to implement new changes.”

Yes, we all know these changes come slowly and likely more queries are in our future related to the terms used to describe pressure ulcers or pressure injuries.

We as CDI professionals must be aware of changes in terminology that are communicated to our providers and assist them in understanding the wording needed to obtain the most appropriate code. Pressure ulcers are important to capture as related to proper MS-DRG assignment, specific quality measures, and risk adjustment. We need to ensure these injuries are captured effectively.

Additionally, ACDIS submitted a question to AHA Coding Clinic for ICD-10-CM/PCS related to this change. We have asked that the term “pressure injury” be accepted as meaning pressure ulcer. Stay tuned as we await the answer. But in the meantime ensure you capture this diagnosis appropriately within the record and likely if your providers adopt this new terminology you will need to add a query for clarification.

Editor’s note: Brodie is a CDI education specialist for HCPro in Danvers, Massachusetts. Contact
her at For information regarding CDI Boot Camps offered by HCPro, visit

Note from the CCDS Coordinator: Onsite exam scoring available now

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

Onsite scoring enabled at remote testing centers.

by Penny Richards 

Live onsite scoring for the CCDS exam began again last Friday, April 15. This is welcome news for those waiting patiently for exam results and for those waiting to schedule their credentialing test until onsite scoring became available. The updated test includes questions on quality measures, ICD-10-CM/PCS concepts, and other items which reflect the changing expectations of those working in the CDI field.
The CCDS Exam Committee and AMP, the company which administers the exam, established 89 as the passing grade. This means candidates must get 89 of the 120 scored questions correct in order to pass the test, which translates to a passing percent of 74%.
The CCDS Exam Study Guide includes a practice test to help you get a feel for the actual exam. The CCDS Exam Study Guide remains the only approved exam resource. CDI Boot Camps are not designed as test preparatory classes, even though they are extremely valuable for foundational knowledge.
On a side note, there will be no on-site, paper-and-pencil CCDS examination following the Atlanta conference this year.

As always, feel free to drop me a note if you have questions.


Weekend Reading: Hierarchical condition classifications

The Physician Advisor's Guide to CDI.

The Physician Advisor’s Guide to CDI.

The Balanced Budget Act of 1997 required a new payment method to adjust Medicare+Choice payments to account for variations in per-capita costs based on health status and other demographic factors. Some of those demographic factors were:

  • Age
  • Sex
  • Medicaid status
  • Disability
  • Original reason for Medicare entitlement

So, the risk adjustment was based on the health risk of the patient. However, only 10% of Medicare+Choice payment rates were risk adjusted, and the other 90% were subject only to demographic adjustments. The Benefits Improvement and Protection Act of 2000 took this risk adjustment methodology to the next level and increased the payment ratio to:

  • 30% in 2004
  • 50% in 2005
  • 75% in 2006
  • 100% in 2007

In 2001, CMS developed a risk adjustment approach that balanced payment accuracy against the data burden for physician and outpatient hospital encounters. The result, in 2002, was the Hierarchical Condition Category (HCC) system.

The HCCs are diagnosis-code driven and include approximately 70 distinct disease groups derived from approximately 3,600 diagnosis codes which are mostly chronic but include some acute conditions, used primarily for outpatient services.

In 2003, President George W. Bush signed the Medicare Modernization Act, which created the Medicare Advantage program reliant solely on HCCs for payment. Medicare Advantage took the place of the previous Medicare+Choice program. Individuals who meet the criteria of the Medicare Advantage programs may have “special needs,” such as mental health concerns, long-term care, or end-stage renal disease (ESRD). The ranking of the diagnosis codes within the HCCs relates to the increased dollars received by the health plan to combat the increase in payment which providers of services receive for these high-cost cases within the healthcare system.

One of the goals of the Patient Protection and Affordable Care Act (ACA) signed into law by President Barack Obama in 2010 is to encourage provider efficiency. CMS defined “efficiency” as a ratio of observed-to-expected costs and outcomes for selected populations.

Essentially, the HCC is used to predict an individual beneficiary’s healthcare expenditures relative to the average beneficiary. These scores are used to adjust payments based on the health status (diagnostic data) and demographic characteristics (such as age and gender) of an enrollee. For example, if it costs 100 physicians $1,000 to treat a condition and it costs Dr. Kennedy $1,500 to treat a patient with that condition, Dr. Kennedy could be penalized when it comes time to adjust the payments based on risk assessments.

Furthermore, efficiency measurement metrics influencing reimbursement may be reported on CMS’ Physician Compare website.

Editor’s Note: This excerpt came from the Physician Advisor’s Guide to Clinical Documentation Improvement. Want to learn more about becoming an effective physician advisor? Consider attending our pre-conference session, Physician Advisor’s Role in CDI Boot Camp, at the annual ACDIS conference. Click here for more information.

Conference Update: Medical necessity reviews

Megan Buyrn

Megan Buyrn

The 2016 ACDIS conference takes place next month on May 23-26, in Atlanta. The ACDIS office is already buzzing with excitement as enter the final weeks of preparation. There is still plenty of time to sign up for the event. Remember, register a team of four and the fifth person attends for free! Call our customer service team for assistance 877-727-1728.

To view the full agenda and details, download the conference brochure. As you start to plan your itinerary, we’re we are interviewing a handful of speakers to give you a feel for the sessions. This week, we spoke with Megan Buyrn, BSN, RN, CCDS; Pence Livingston, BSN, RN; and MaryKate Rentschler, MBA, BSN, RN, who will present, “Medical Necessity Reviews: CDI impact on provider documentation.”

Q: Tell me a little but about the process that your facility took to improve documentation of medical necessity.  

Buyrn: Our emergency room providers decide the level of care at our facility, so we started with their documentation. We first conducted baseline audits, shared the results with the providers, and implemented other interventions, such as form revisions and tip cards. We then conducted continual follow-up audits with regular feedback and results for a two-year period. We expanded this process to include adult medicine, psychiatric, and pediatric inpatient areas.

Q: What are three things attendees can expect from your session?

MaryKate Rentschler

MaryKate Rentschler

Rentschler: First, we’ll help them identify opportunities to improve attending documentation of medical necessity for observation and inpatient hospitalization in order to decrease denial vulnerabilities. We will discuss how to develop a process for retrospective audits of observation, inpatient, and short stay ICU admissions. Finally, we will outline strategies to help improve physician compliance and hospital system processes through educational tools and strategic distribution of audit results.

Q: Who should attend your presentation and why?

Livingston: CDI specialists, physician advisors, utilization review staff, or anyone interested in medical necessity documentation for inpatient stays.

Q: What do you think is the most important quality for a CDI professional to have?

Buyrn: Here at Denver Health, flexibility is so very important. The scope of our skillset is broad and constantly shifting with the changing needs of the hospital and the healthcare rules and regulations. CDI specialists have to be open to learning new skills and finding ways to apply their newfound knowledge and educate others.

Q: What are you most looking forward to about this year’s conference? What is your favorite part of the conference?

Rentschler: We look forward to hearing how other programs are succeeding, including innovative ways that CDI is affecting hospital processes.


Guest Post: Documentation requirements for observation services

Kimberly Anderwood Baker Hoy

Kimberly Anderwood Baker Hoy

by Kimberly Anderwood Hoy Baker, JD

Medicare covers observation care as an outpatient service under Part B payments. (Medicare reimburses different healthcare providers under different systems or parts—Part A for hospital payments, Part B for medical/doctor’s services, Part C which allows private insurers to provide Medicare benefits, and Part D for outpatient prescription drugs.) The Medicare Benefit Policy Manual defines observation as a:

“well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.”

Two key parts of this definition are the assessments and decision. Medicare mentions assessments and reassessments, presumably to emphasize the active period of care leading to the decision to discharge the patient or admit him or her as an inpatient. Once a decision has been made regarding the patient’s disposition, the care no longer meets this definition of observation, which becomes especially important if the decision has been made to discharge the patient to an alternate, lower level of care that is not available. In these cases, the continued care at a lower level, in lieu of discharge, does not meet the definition of observation because the decision to discharge the patient has been made.

Documentation requirements

Observation services can be ordered by physicians and other providers authorized by state law and hospital bylaws to admit patients or order outpatient tests. Physicians (e.g., emergency department [ED] physicians) who can order outpatient tests may order observation services even though they may not be authorized under hospital bylaws to admit patients for inpatient status. This allows some flexibility for placement of patients in observation. Note that standing orders for observation after surgery are not accepted. Orders for observation must be specific to the patient’s need for continued monitoring in response to clinical factors.

In addition to the order for observation, documentation must reflect that the patient is in the care of a physician. The Medicare Claims Processing Manual requires notes at the time of registration and discharge as well as other appropriate progress notes to be “timed, written, and signed by the physician.” The manual’s emphasis on the physician writing the progress notes aligns with the requirement for assessment and reassessment in the definition for observation. Assessing and reassessing a patient in observation ensures the patient is receiving active care and not simply a lower, custodial level of care.

Like other services covered by Medicare, observation must be reasonable and necessary or, in other words, medically necessary. The physician must document that he or she assessed patient risk to determine that the patient would benefit from observation services. Documentation should describe:

  • what risks are present that prevent the patient from being safely discharged home or to a lower level of care
  • how the patient would benefit from further observation at the hospital

Documentation of this assessment provides the basis of the medical necessity of the observation services.

Editor’s Note: This article was originally published in Patient Status Training Toolkit for Utilization Review.

Tip: Motivate providers with comparitive data

Jane Hoyt

Jane Hoyt

Are you looking for a quick and easy way to engage your providers? Homemade baked goods and gifts recognizing consistent high quality documentation are a viable option. But, while treats are great for some, the best strategy for motivating providers can, in many cases, be their own track records, says Jane Hoyt, BSN, RN, CCDS, CDIP, clinical documentation specialist at the University of Cincinnati Academic Health Center.

“Give them reports on their individual data and compare it to that of their own peers and specialty,” says Hoyt. “Then compare that specialty data to the same specialty in other hospitals within their cohort as well.”

These metrics can come from a number of places such as

  • Leapfrog
  • Physician/Hospital Compare
  • US World & News Reports
  • Consumer Reports

Increased understanding and a little healthy competition breeds sustainable interest and success for providers, hospitals, and CDI programs alike, Hoyt says.

Editor’s note: This tip is an excerpt from the forthcoming May/June edition of the CDI Journal. If you have a tip you’d like to share, post it in the comments section below and join the conversation! The CDI Journal is a bi-monthly online publication and an ACDIS membership benefit. If you’re not a member, join today and catch up on all the tested tips and tools from your CDI peers!



A Note from the ACDIS Editor: Thanks for getting social with us!

Katy Rushlau

Katy Rushlau

by Katy Rushlau

For those of you who follow ACDIS on social media—yes, we’re on Facebook, Twitter, and LinkedIn—you know that last week was a pretty big week for us. We launched our first ever daily giveaway, where we asked you, our followers, to like, share, and tag a friend in a post for a chance to win a copy of our Physician Advisor’s Guide to CDI. In total, we gave away eight books, had 155 shares, received 131 post likes and 60-plus page likes, and reached nearly 6,500 people.
What does all of that mean? To me, it speaks to the strength of the ACDIS community, and the power social media has in terms of bring us together. In this social media era, it’s important for groups like ours to take advantage of these settings to learn from one another, start discussions, and grow. While ACDIS provides numerous formal opportunities to network—the conference, local chapters, and CDI Talk come to mind—joining in on our various social platforms is a wonderful (and casual) way to connect, as well.
With every like, share, and comment, we’re doing something even more critical—boosting our reach. Last week, those nearly 6,500 people who saw our posts might not have seen them if it weren’t for all of you who participated in our contest. With the vitality of our presence on social media, ACDIS will be able to reach individuals throughout the country and world who may not have otherwise known we existed.
So, I encourage you, if you haven’t already, to please connect with us via social media. This is about so much more than a free book or a page like. It’s about reaching others who may benefit from our collective resources and knowledge so we can learn from each other. And to all of you who already do, thank you for strengthening our online voice and keeping our social media presence alive and well.