RSSAuthor Archive for Linnea Archibald

Linnea Archibald

Linnea Archibald is the CDI editor for the Association of Clinical Documentation Improvement Specialists (ACDIS). In this role, she helps out with the website, blog, social media, newsletter, and the CDI Journal. If you have any questions, feel free to email her.

Guest Post: Expanding the CDI focus to the outpatient arena, part 2

Editor’s note: Crystal Stalter, CPC, CCS-P, CDIP, is the CDI manager for M*Modal in Pittsburgh. She has over 30 years of experience in the healthcare industry, with most of her focus on coding, compliance, and physician documentation. She has spent many of those years as a consultant, working with physicians and hospital HIM departments to improve their workflow processes and revenue cycles. Contact her at crystal.stalter@mmodal.com. Opinions expressed are that of the author and do not represent HCPro or ACDIS. This article was previously published in Briefings on APCs and JustCoding. This is the second part of a two-part series. To read the first part of this article, click here.

There are multiple outpatient places of service the CDI specialist can have an impact. One such place is the ED, where capture of ancillary services, start and stop times (as well as medications and dosages for injection/infusion coding), and evaluation and management (E/M) code (the codes assigned for physician reimbursement) levels often get missed or are incomplete, causing subsequent coding issues.

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Q&A: Documenting excisions in dermatologic settings

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Have CDI questions?

Q: I work in dermatology and need to know what documentation is required for excisions. We are struggling with getting paid.

A: In dermatology, you often find vague documentation like “lesion” and “mass.” So the physician needs to be much more graphic as far as whether the lesion is red, itchy, scratchy, burning, and/or abnormally sized. If you can get the actual size of a lesion or a mass that they are going to excise, they also need to document the size of the excision.

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Note from the ACDIS Editor: CDI Journal provides training tactics

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ACDIS Editor Linnea Archibald

By Linnea Archibald

New hire training. Ongoing education. Physician education. Each area holds unique difficulties for the CDI professional in all stages of their careers. Keeping all the CDI staff and physicians on the same page can be a daunting and headache-inducing task. For that reason, the July/August edition of the CDI Journal seeks to outline a few strategies, tips, and tricks from seasoned veterans in the field for keeping your whole team engaged and up-to-date in their CDI education.

Within the pages of the newest edition of the CDI Journal, you’ll find valuable information from a variety of perspectives—from CDI specialists conducting daily reviews, to CDI educators, to the ACDIS Advisory Board members, to the ACDIS leadership team and staff. [more]

Guest Post: Expanding the CDI focus to the outpatient arena, part 1

Editor’s note: Crystal Stalter, CPC, CCS-P, CDIP, is the CDI manager for M*Modal in Pittsburgh. She has more than 30 years of experience in healthcare focused on coding, compliance, and physician documentation concerns. Contact her at crystal.stalter@mmodal.com. Opinions expressed are that of the author and do not represent HCPro or ACDIS. This article was previously published in Briefings on APCs and JustCoding. This is the first part of a two-part series. Please return to the blog next week to read the second part!

The focus for CDI specialists has historically been on the inpatient hospital stay. Reviews of the chart for conditions not fully documented and/or evidence of conditions not documented at all, has been standard practice.

However, with so many changes in the industry facing providers in their outpatient practices, the importance of CDI in places of service such as physician offices, ambulatory clinics, and urgent care clinics is even more vital.

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Symposium update: Early bird pricing ends today

outpatient early bird

Early bird pricing ends today!

Today is the last day to get the Early Bird price for the first ever ACDIS Symposium: Outpatient CDI. Reserve your seat today, July 17, to take full advantage of the discount. The conference takes place from September 18-19 at the Hilton Oak Brook Resort and Conference Center in Oak Brook, Illinois.

ACDIS members receive a $100 discount on their conference tickets, bringing the price down to $805. [more]

TBT: 2017 Conference Committee member shares session insight

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Faisal Hussain, MD, CCDS, CDIP

By Faisal Hussain, MD, CCDS, CDIP

It was a real privilege to serve on the 2017 ACDIS Conference Committee, even though it involved a lot of hard work, and tough decisions regarding the selection of speakers and award winners.

One of the sessions that caught the interest of the entire committee concerned objectively measuring providers’ clinical engagement. What made this session even more special was the fact that the presenter, Nicole Draper, RN, BN, MHA, DH-C, was responsible for putting together one of the first CDI programs in Australia.

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Behind the scenes at ACDIS: E-learning producer brings back industry-leading tips

Editor’s note: From time to time, we like to take a moment to share a behind-the-scenes look at what the ACDIS and broader HCPro team has been working on. Today, we wanted to shed some light on one of our e-learning producers, Amanda Southworth. Amanda recently attended the Association of Talent Development International Conference and Exposition (ADT) in Atlanta and brought back a number of important lessons about education, training, and e-learning. To see the complete list of HCPro’s e-learning opportunities, click here.

I recently had the privilege of attending the ADT, a massive four-day educational and networking event that included 10,000 learning and development professionals from all over the world. While there, I learned about the latest trends in the training world as well as the specific struggles, challenges, and successes specifically related to providing continuing education to those working in the healthcare field.

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Symposium Speaker Highlight: McCall demystifies outpatient coding

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Shannon McCall, RHIA, CCS, CCS-P, CPC-I, CCDS

Editor’s note: As we did with the 10th annual ACDIS conference in May, we’ll take some time leading up to the ACDIS Symposium: Outpatient CDI to chat with a few of the speakers. The event takes place September 18-19 at the Hilton Oak Brook Resort & Conference Center in Oak Brook, Illinois. Today, we talked with Shannon McCall, RHIA, CCS, CCS-P, CPC-I, CCDS, the director of coding and HIM at HCPro in Middleton, Massachusetts. She manages the instructors of the Certified Coder Boot Camps and has extensive experience with coding for both physician and hospital services. She will be presenting “The Ins and Outs: Inpatient and Outpatient Coding” on Day 1 of the Symposium.

Q: There are so many differences between inpatient and outpatient coding! What would you say is the most difficult one(s) for those moving from the inpatient CDI world to wrap their minds around? (e.g., that words like probable, likely, suspected don’t count toward a diagnosis, that outpatient facilities not only use ICD-10 but also CP[SM] T, the different code sets each have their own set of guidelines and rules governing use?)

A: Documentation for outpatient encounters is much briefer than documentation for an inpatient admission so the application of the guidelines of only assigning codes for relevant diagnoses is important. Providers typically lack the documentation in their notes to clearly identify chronic conditions being clinically relevant in their decision making process. Since risk adjustment is based on diagnosis coding, the differences in procedure coding has no bearing.  [more]

Q&A: Missing documentation for acute kidney injury

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Ask ACDIS all your CDI questions!

Q: We are currently coding a chart for an acute kidney injury which has the baseline serum creatinine and urine output missing from the chart. Is there something we can do to identify additional information before we have to query the physician?

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Tip: Show your ACDIS and CDI pride

With CDI Week 2017 only 74 days away, it’s time to get planning as to how you’ll show your CDI pride. In the past, CDI programs have taken whole team pictures together, thrown lunch parties, held after-hours get-togethers outside of the office walls, extended thanks to the most helpful physicians, and worn CDI-themed outfits to work.

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