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.

CDI Week 2017: Celebrations nationwide

Last week, ACDIS celebrated our seventh annual CDI Week, recognizing professionals across the country for the incredible work that they do. Facilities and local chapters nationwide joined the fun, embracing the 2017 theme, “The Wild West: New Frontiers in CDI,” fully.

We were lucky enough to get our hands on a few photos from last week’s activities. Please enjoy this little slideshow we put together. Thanks for another great CDI Week!

CDI Week Q&A: CDI and Technology

Wall, James

James Wall, RN-TN, BSN, MBA

As part of the seventh annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. James Wall, RN-TN, BSN, MBA, the senior director of clinical documentation improvement at LifePoint Health in Brentwood, Tennessee, and a member of the 2017 CDI Week Committee, answered these questions on CDI and technology. Contact him at james.wall@lpnt.net

Q: How long have you had electronic health records?

A: I am a systems Senior Director of CDI. Since LifePoint has acquired many hospitals, we have assumed a variety of different EHR systems. While there is not a standard EHR, LifePoint uses three main Health Information Systems. Many of our hospitals are totally electronic while others are a hybrid of EHR and paper.

Q: Have there been any real sticking points with the transition to full electronic systems? [more]

CDI Week Q&A: CDI and Quality

Ignatowicz

Nancy Ignatowicz, RN, MBA, CCDS

As part of the seventh annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Nancy Ignatowicz, RN, MBA, CCDS, a remote/traveling CHI nurse with MedPartners, based in Bourbonnais, Illinois, and a member of the 2017 CDI Week Committee, answered these questions on CDI and quality. Contact her at nrmignatowicz@comcast.net.

Q: Can you describe the relationship of CDI to quality initiatives, and how CDI can make a difference?

A: CDI and quality can have a variety of relationships. For instance, CDI can offer concurrent notification of actual or potential issues to the quality department. CDI can assist with concurrent data collection and quality interventions. CDI queries can also address present on admission status, cause-and-effect relationships, surgical puncture/laceration specificity, risk of mortality, and severity of illness. For example, CDI can help capture pressure ulcers, catheter-associated urinary tract infections, pathological fractures (which may have been diagnosed intra/postoperatively), surgical lacerations integral to the procedure, and diagnoses that were present on admission but not previously identified in the documentation.

Q: Has reviewing for quality measures hindered your department’s “traditional” CDI chart reviews or overall productivity? [more]

CDI Week Q&A: CDI Expansion

Peppers, Rhonda

Rhonda Peppers, RN, BS, CCDS

As part of the seventh annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Rhonda Peppers, RN, BS, CCDS, a CDI specialist at Care Coordinators, MedPartners, in Tampa, Florida, and a member of the 2017 CDI Week Committee, answered these questions on CDI expansion. Contact her at rhondapeppers@benefis.org.

Q: When did you first get involved in CDI, and what was your CDI program’s focus?

A: I started working in CDI in 2011, and our program’s focus was on earning money. We were given monthly monetary totals on the queries we wrote. We were very competitive. Our goal was to see who could make the most money. As a matter of fact, I was told when I first started that we were not to write the query if it was for severity of illness (SOI) or risk of mortality (ROM), just write the ones for MCCs and CCs.

Q: How has the focus of your CDI program changed over the years? [more]

CDI Week Q&A: Career Advancement

Ng, Brenda

Brenda Ng, MS, RN, CCDS, CCS

As part of the seventh annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Brenda Ng, MS, RN, CCDS, CCS, a CDI consultant at MedPartners in Greenwood Lake, New York, and a member of the 2017 CDI Week Committee, answered these questions on CDI and career advancement. Contact her at ngbrnd@yahoo.com.

Q: What, in your mind, does the “typical” CDI specialist role entail?

A: The typical CDI specialist role entails knowledge of best practices, quality reviews, continuity of care, and ensuring that patients are receiving the right communication.

Q: As CDI programs advance, they begin to branch out into other review areas. What areas do you think programs should move into first? [more]

Q&A: Credentialing for outpatient CDI

Have CDI questions?

Have CDI questions?

Q: I’ve heard lately that outpatient CDI specialists are less likely to be registered nurses. Is there a reason there may be more coders in this arena?

A: While many outpatient CDI specialists do hold an RN credential, there are good reasons for having coders fill the roll, says Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for HCPro in Middleton, Massachusetts.

“There are a lot of very specific documentation requirements for evaluation and management (E/M), observation codes, interventional radiology, etc., which RN CDI specialists don’t typically learn,” he says. Additionally, coders may already be comfortable working in a physician practice setting and have a familiarity with hierarchical condition categories (HCC). [more]

Guest post: 2018 ICD-10 codes—when the heart needs a helping hand

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Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS

by Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS

Congestive heart failure (CHF) is a commonly diagnosed condition where the ventricles or the lower chambers of the heart do not work effectively. The heart serves as a pump to get blood in and then out of the heart to circulate to the rest of the body. When any type of pump doesn’t work efficiently backups can occur.

The most common form of CHF is left ventricular failure, however left-sided failure can also lead to right ventricular failure as a ripple effect. There are two common types of CHF, one whereby the ventricle cannot contract normally, known as systolic heart failure, and one where the ventricle cannot relax normally due to stiffness, known as diastolic failure. Some patients may have a combination of both systolic and diastolic failure.

The causes of heart failure include hypertension, coronary artery disease, and valvular diseases, as well as cardiomyopathies. [more]

Guest Post: Communication eases challenges of fiscal year 2018 code changes

coding changes

On October 1, over 800 code changes take effect!

by Crystal Stalter, CDIP, CCS-P, CPC

It’s that time of year again—time to wonder just how the 2018 IPPS final rule will affect CDI and coding efforts.

The 2018 IPPS final rule includes more than 800 ICD-10-PCS changes. Previously recognized operating room codes have become non-operating room codes, affecting DRG assignment, changing surgical DRGs to medical DRGs, and thus affecting reimbursement. Some diagnoses are gaining new definitions and explanations that will result in new ICD-10-CM code assignments and shift DRGs as well.

[more]

UnitedHealth Group, Inc. vs. the United States of America: The case for CDI, part 2

Brian-Murphy

ACDIS Director Brian Murphy

By Brian D. Murphy

In Part 1 of this series I introduced the developing story of UnitedHealth Group, Inc. vs. the United States of America, and my intent to write a series of articles on this civil fraud action. Why? Because I find this to be an incredibly interesting case with broad ramifications for CDI and coding departments.

So let’s review the basic at the facts of the case, starting with the who and when. [more]

Tip: The four E’s of staff education

journal banner summer

Brush up on some education tips and tricks!

by Amanda Southworth

Educating CDI staff and physicians alike can be a challenge. With busy schedules, resistant physicians, and a constantly changing healthcare environment, even the most seasoned educator can feel like pulling their hair out.

By keeping in mind four E’s, however, educating becomes a bit more manageable.

Efficient: Educational sessions should seek to get to the point quickly. With busy and fluid schedules, each educational session should have a focused point. Even if the timeframe incorporates a couple different subjects—say, clinical indicators and querying—each section still needs a point and direction. This will cut down on wasted time during your limited education space. [more]