Author Archive for Brian Murphy

Next ACDIS quarterly conference call Nov. 19

Hi ACDIS members,

Our next quarterly conference call is scheduled for Thursday, November 19, from 2-3 p.m. ET. This is a members-only call and dial-in instructions were e-mailed out to our membership list yesterday and today.

Please note: If you did not recieve an e-mail notification, and you are an ACDIS member, please e-mail ACDIS member relations specialist Sue Calabro at customerservice@cdiassociation.com. Sue will provide you with the dial-in number and passcode.

These calls are offered as a means for ACDIS members to network with one another, and to discuss any clinical documentation improvement related issues. We will have a few ACDIS Advisory Board members on the call as well. We encourage your comments, thoughts, and questions during the call. Additionally, if you have any suggestions for discussion that you would like to forward along to our advisory board, please e-mail me at the address below.

If you cannot attend the call, we will provide a digital recording for download on our Web site.

Thanks, and I hope you can dial in on the 19th.

Brian Murphy

bmurphy@cdiassociation.com

Supplement to October 2009 CDI Journal: Coding Clinic update

Hi ACDIS members, if you go to our CDI Journal home page you will find a special supplement to the October 2009 issue: A special report reviewing the important developments and guidance in Coding Clinic for ICD-9-CM, third quarter 2009. The source of the article is James Kennedy, MD, CCS, director of FTI Healthcare consulting and author of the Physician Queries Handbook.

In this article Dr. Kennedy breaks down the latest Coding Clinic as it pertains to CDI specialists, reviewing important sequencing considerations, query opportunities, and more. Going forward, ACDIS plans to make this a regular feature exclusively for our membership. Coding Clinic for ICD-9-CM is a vital component of every CDI specialists’ toolbox, and we hope you find the article useful.

If you have any feedback for Dr. Kennedy, please feel free to post it right here.

Take care,

Brian

Back from Boot Camp

If I’m looking a bit sore and stiff this week, it’s because I’m still recovering from our latest Clinical Documentation Improvement Boot Camp in Alpharetta, GA. No, no push ups or early morning runs were involved, just a lot of exercise for the mind.

I had the chance to attend the first 2 1/2 days of the four-day Boot Camp, and can honestly say I

There's no screaming at the CDI Boot Camp. We promise.

learned a lot from our instructor, Catherine O’Leary of CSG Solutions. Catherine has extensive experience as a nurse in medical/surgical intensive care, and her clinical knowledge and experience shines in the heart of the Boot Camp–a guided tour of the Major Diagnostic Categories (MDCs), including infectious diseases, the respiratory, circulatory, digestive, endocrine, and neuro systems, and much more. I learned more about “the left shift” and neutrophils than I ever did before, as well as coding/sequencing guidelines for sepsis.

Another strong point of Catherine’s background is her familiarity with the RAC program. She worked with several New York hospitals hard-hit by the RAC demonstration program, and has some great ideas to share for getting CDI specialists more involved with the RACs to prevent denials on a proactive basis.

The CDI Boot Camp is also a great place for discussions and networking with your colleagues. The goal of the CDI Boot Camp is to provide a small, classroom-like learning environment to teach the core skills and basics of the CDI profession. This small teacher-student ratio allows for a lot of dialogue with the instructors and each other. Many of our students took the opportunity to meet up for dinner and exchange business cards and phone numbers. I personally got to speak with several ACDIS members, including a few who I knew by e-mail signature only. It was a pleasure to be able to put real faces to names.

In summary, I hope all of our new CDI specialists, or CDI specialists in need of some additional training, make it out to a Boot Camp. And don’t fear the name: No sit ups and pull ups required, I promise.

Q&A: Coding from NP documentation

Question: If a CDI specialist puts a sticker in the chart and a nurse practitioner (NP) signs it, can the coder code that diagnosis legally?

Answer: ICD-9-CM guidelines allow code assignment from a NPs documentation so it is important that you seek a compliant policy. I would suggest that you seek the NP scope of practice specific to your state. Although most states have similar scopes of practice, they can differ. I would suggest that you meet with your compliance department to create a facility specific policy regarding the NP scope of practice, and seek medical staff approval on the policy.

A sticker in the chart however is larger source of concern. It is not considered a valid part of a medical record and coding staff cannot report from something that is not part of the legal medical record. Additionally, signing your note as a method of agreement is not clinically valid data entry by a provider of medical care.  There is not enough documented proof that the person did anything other than sign (without reading) the note, and that kind of “validation” would not be supportable as a clinical decision.  A physician who signs the progress note of a medical student or nurse is not a substitute for the physician’s entry of the same verbiage in the medical record and will not stand under legal scrutiny. 

(Robin Holmes and Robert Gold of the ACDIS advisory board answered this question)

Does your hospital use the Epic software system? Let’s hear about it

Hi ACDIS members, I’ve had a few questions recently regarding the Epic software system. It was a subject of a member’s question on the most recent quarterly conference call, and I’ve since received a few additional e-mails from facilities that are going to Epic, or plan to do so, and are looking for help from experienced Epic users who have been using the system to leave electronic queries and interface with physicians.

If you would like to share your e-mail address, please feel free to leave it right here by leaving a comment on this post, or you can e-mail me directly at bmurphy@cdiassociation.com.

With more and more facilities going electronic, it would be great to see members sharing best practices, implementation strategies, and other ways of helping one another out with this important transition.

Take care,

Brian

New article of the month: Complications of surgery

Hi ACDIS members, there’s been a lot of talk regarding complications of surgery during our quarterly conference calls. In response, we worked with Dr. Robert Gold of DCBA, Inc. and the ACDIS advisory board, and Mario Perez of J.A. Thomas & Associates, to bring you a new article of the month on the subject.

Please click here to view the article or visit our main page.

As a reminder, you can find an archive of previous articles of the month (as well as many other articles and links) on our helpful resources page.

Take care,

Brian

CCDS recertification web pages up

Hi ACDIS members, for those who have achieved their Certified Clinical Documentation Specialist (CCDS) certification, please note that we now have informational web pages up regarding recertification. You can find them by clicking on our certification tab, and then clicking the recertification link in the upper right-hand corner of the page. I’ve also included a direct link here.

Recertification occurs every two years from the date on which you passed the CCDS exam, and is accomplished by submitting 20 CEUs and a certification maintenance fee. Recertification is critical because it ensures that you stay up to date on the latest regulatory updates, trends, and updates to this ever-changing profession. We will accept all CEUs relevant to the profession (i.e., attending AHIMA, case management, or other related conferences, submitting nursing CEUs, attending inpatient coding seminars, etc.).

More information on the type of CEUs we will accept, and on calculating your CEUs, can be found on our recertification pages.

If you have any questions don’t hesitate to contact me.

Thanks,

Brian

bmurphy@cdiassociation.com

Reminder: Dial in for Thursday’s quarterly conference call

Hi everyone, just as a reminder, the Association of Clinical Documentation Improvement Specialists (ACDIS)  recently announced the date of its next quarterly conference call: Thursday, August 27 from 1-2 p.m. ET.

These calls are offered as a means for ACDIS members to network with one another and to discuss any clinical documentation improvement related issues. We have a few ACDIS Advisory Board members on the calls as well to help spark discussions.

We encourage your comments, thoughts, and questions during these calls. If you have any suggestions for discussion that you would like to forward along to our advisory board, please e-mail me at the address below.

ACDIS members have recieved e-mail instructions in advance of the call with dial-in instructions. If you are an ACDIS member and did not receive your instructions, or misplaced them, please e-mail ACDIS member relations specialist Sue Calabro at customerservice@cdiassociation.com .

Thanks,

Brian Murphy, ACDIS Director

bmurphy@cdiassociation.com

Talk the CDI Talk

Join the CDI discussion

I don’t know how many of you subscribe to CDI Talk, but I think you’re missing out if you’re not subscribed. CDI Talk is an active talk group of ACDIS members and generates a lot of great discussion. It’s a good way to keep updated on the issues affecting CDI programs around the nation, and I would love to have you weigh in on the conversations. Signing up is easy (and free with ACDIS membership):

• Sign in to the ACDIS Web site (www.cdiassociation.com) with your password and username
• Go to our CDI Talk page, here: http://www.hcpro.com/acdis/cdi_talk.cfm
• Click the gray “subscribe button”
• Post messages by using the “create new message” button, or by sending a message to cdi_talk@hcprotalk.com.

ACDIS CDI Work Group update: Group chosen, work to begin

Hi everyone, I thought I would take a moment to provide an update on an exciting new initiative going on with ACDIS: the CDI Work Group. This is a group that, beginning in the next few weeks, will start a series of bi-weekly meetings to discuss common obstacles and best practices in the field of clinical documentation. Its goal is to produce detailed surveys, benchmarks, and best practices to share with the membership.

I’m personally very excited about this group and strongly believe that the diverse expertise it brings to the table–and the work it ultimately produces–will be of immense value to our ACDIS members.

We had over 50 applicants for the CDI Work Group but in the end we had to narrow it down to 15. The CDI Work Group consists of the following members:

• Cheryl Ericson, MS, RN, Clinical Documentation Improvement Manager for The Medical University of South Carolina
• Lisa Peterson, BS, RHIA, Manager of the Medical Record Department for the University of Tennesee Medical Center
• Jennifer Woodworth, RN, BSN, Manager of Clinical Documentation for MultiCare Health System in Tacoma, WA
• Glenda Hebert, RN, BSN, CCM, Clinical Documentation Specialist for CHRISTUS Hosptial St. Elizabeth in Texas
• Susan Payne, RN, BSN, Manager of Case Management/Social Services for Sharp Chula Vista Medical Center in California
• Eileen Hickey, RHIA, Coordinator of Medical Record Services for Atlantic Health-Morristown Memorial Hospital in New Jersey
• Karen Frosch, CCS, Clinical Documentation Manager for Christiana Care in Delaware
• Lena Wilson, RHIA, CCS, Manager of HIM Operations/Clinical Documentation Improvement Program for Clarian Health in Indiana
• Thenia Nesbeth-Blades, RN, MSN, CDI Specialist for New York Presbyterian Hospital-Columbia
• Luanne Jennex, RN, CDI Specialist for Westchester Medical Center in New York
• Donald Butler, RN, BSN, Manager of Clinical Documentation for Pitt Country Memorial Hospital in North Carolina
• Sue Muse, RHIA, CDI Director for Precyse Solutions in Kentucky
• Marta Boyd, RN, Documentation Specialist for Valley Hospital and Medical Center in Washington
• Adelaide LaRosa, RN, Director of the Clinical Documentation Improvement Program for St. Francis Hospital in New York
• Pat Danks, CCS, CPC, CPC-H, CCDS, Coding Quality and Compliance Consultant for Kindred Healthcare

The group will be directed by three members of the ACDIS Advisory Board, including Shelia Bullock, Wendy DeVreugd, and Garri Garrison. In addition, I’ll be participating as well.

The CDI Work Group will be an ongoing project and will attempt to address many issues within the profession, starting with staffing considerations. Over time we may be looking to add members of different backgrounds and experience to participate, so stay tuned.

Thanks,

Brian