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.

Tip: Take a closer look at POA reporting guidelines

The 2017 ICD-10-CM Official Guidelines for Coding and Reporting brought many changes and updates for coders, and present on admission (POA) reporting was not excluded. Completely understanding POA guidelines is necessary for any inpatient coder or CDI specialist.

Per the Guidelines, POA conditions are defined as those present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, such as an emergency department, observation, or outpatient surgery, are also considered POA. A coder would assign the POA indicator to a principal or secondary diagnosis.

Think of understanding POA indicators as “part two” of understanding coding rules, says Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, and coding regulatory specialist at HCPro, a division of BLR, in Middleton, Massachusetts.

“Once the codes have been assigned for an inpatient record, a coder then must go back and evaluate each one for the appropriate indicator,” Commeree says. Also important to remember is there is no required time frame that a provider must document a condition for it to be considered POA, so CDI professionals can still clarify conditions as POA through their efforts, as well. It could take several days for a provider to assign a diagnosis. Because it may take a provider several days to arrive at a diagnosis does not mean that the condition was not POA. Determination of whether the condition was POA is based on the Guidelines and on the provider’s best clinical judgment, Commeree says, since according to the Guidelines:

“In some clinical situations, it may not be possible for a provider to make a definitive diagnosis (or a condition may not be recognized or reported by the patient) for a period after admission.”

The Guidelines also state that if at the time of code assignment, the documentation is unclear as to whether a condition was POA, it is appropriate to query the provider.

“If we’re not sure if it was POA—it wasn’t explicitly documented as POA, diagnosed prior to admission, or diagnosed during the inpatient admission but seems POA by indication of signs and symptoms—it’s not up to us to decide. A query to the attending provider is the best course to take.”

Editor’s Note: This article originally appeared in JustCoding. To access the original article, click here.

Guest Post: Creating an inpatient coding compliance plan

Rose Dunn



To limit exposure to claim denials and external reviews, the best safeguard for a facility is a robust, effective internal coding compliance policy, plan, and program.

Begin by reviewing any existing coding policies and procedures to determine whether they are consistent with the organization’s compliance plan, as well as the latest Official Guidelines for Coding and Reporting. If your department lacks compliance policies and procedures, excellent resources are available at JustCoding, ACDIS, AHIMA and the Hospital Corporation of America.

A facility’s coding compliance plan may be a subsection of the policy. If you format your compliance plan as a subsection, the document should be labeled “coding compliance policy and plan.” The plan component should be much more detailed and include the specifics of what, when, and how often. Each organization should tailor its coding compliance plan to its organization.

When developing a new coding compliance plan, managers should begin by asking these questions:

  • Why am I establishing a plan?
  • What will I review?
  • How will I select a sample?
  • How will I assess accuracy?
  • What action will I take when the results are known?
  • How will I monitor progress?

The coding manager should collaborate with the compliance officer in developing the plan. Some components that should be considered when you create your plan are:

Purpose: The purpose of the XYZ Hospital Compliance Plan is to improve the accuracy and integrity of patient data, ensure minimal variation in coding practices, serve as a conduit to improve provider documentation in the electronic patient record, and support XYZ Hospital’s ability to receive its entitled reimbursement for the services it and its providers provide.

Expectation: Staff (employees and, when applicable, contracted staff) will strive to maintain the highest level of professional and ethical standards in the performance of their coding duties. Staff will be trained and oriented in all applicable federal and state laws and regulations that apply to coding and documentation as relates to their positions.

Adherence to these guidelines is imperative. Where any questions or uncertainty regarding these requirements exists, it is the responsibility of the employee to seek guidance from a certified coding specialist, health information administrator, or another qualified coding professional. Staff will be familiar with prohibited and unethical conduct that relates to coding and billing as outlined in the facility compliance plan. Staff will comply with AHIMA’s Code of Ethics.


  • All coders, billers, and providers will receive orientation and training in the fundamentals of compliant coding and billing. Continuing education will be provided in the form of handouts, memos, journals, in-services, and formal education as available and approved. To keep up with changes in regulatory requirements, coding changes, and proper coding procedures, it is the staff member’s responsibility to further his or her knowledge by reading all handouts, memos, and journals provided, and actively participating in available in-services and formal education workshops.
  • All coders, billers, and providers will receive training in coding, documentation, and billing compliance issues on an annual basis or more frequently as need dictates. The training will be coordinated by the coding compliance subcommittee in conjunction with or in addition to training provided by the compliance office.

Coding resources: Coding staff shall have access to the following resources to facilitate their coding duties:

  • Encoder
  • Computer with dual monitors
  • Coding books: ICD-10-CM for diagnoses and ICD-10-PCS for inpatient procedures; other reference materials will be maintained in the coding manager’s office

Coding conventions and guidelines: The guidelines and conventions to be followed for codes to be reported on claims will be:

  • Coding Clinic published by the American Hospital Association
  • Official Guidelines for Coding and Reporting published by CMS and the National Center for Health Statistics

Editor’s note: This article was originally published in JustCoding. Dunn is a past president of the American Health Information Management Association and recipient of its 1997 Distinguished Member and 2008 Legacy awards. In 2011, she served as the interim CEO of AHIMA and received a Distinguished Service Award from its board of directors. Dunn is the chief operating officer of First Class Solutions, Inc., a health information management consulting firm based in St. Louis. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. This article is excerpted from JustCoding’s Practical Guide to Coding Management.


Guest Post: Relevant ICD-10 code proposals for CDI and coders

Allen Frady

Allen Frady, RN, BSN, CCDS, CCS

By Allen Frady, RN, BSN, CCDS, CCS

Editor’s note: The CMS ICD-10 Coordination and Maintenance Committee (CMC) met on March 7 and March 8 to discuss proposed code changes to ICD-10-CM and ICD-10-PCS. The committee is a federal committee comprised of representatives from CMS and the CDC’s National Center for Health Statistics (NCHS). The committee approves code changes, develops errata, addenda, and any other modification to the code sets. These code changes were discussed in hope of being amended in the 2018 code update, active October 1.

Among the many proposed changes to the code set, I noted 16 of particular interest to CDI specialists and coders. Remember, nothing is final until the September meeting of the CDC Coordination and Maintenance Committee(CMC), and of course, the CMS finalization.


Some of the most relevant talking points include possible changes related to heart disease. First, the CMC proposes reclassification of an unspecified acute myocardial infarction (AMI) to I21.9 AMI, including “unspecified myocardial infarction (acute) no otherwise specified (NOS).” Currently, “unspecified AMI” defaults to an STEMI. CDI specialists frequently prod physicians for additional specificity to ensure NSTEMI’s are not inadvertently reported as STEMI’s as it also affect quality standards.

Additionally, an unexpected proposal given the recent AHA Coding Clinic, First Quarter 2017, CMC proposes a new code I21.A1, Myocardial infarction type II (also called a Type II MI). Coding Clinic previously directed Type II MI to be coded as an NSTEMI. CMC’s proposal includes myocardial infarction due to demand ischemia and myocardial infarction secondary to ischemic imbalance as inclusion terms. The new proposed code would have a “code also underlying cause, if known” instructional note in the Tabular Index. Examples of precipitating events included in the proposal are:

  • anemia
  • chronic obstructive pulmonary disease (COPD)
  • heart failure
  • tachycardia
  • renal failure

There are, of course, other possible causes and the list provided is not intended to be comprehensive. This hopefully will circumvent the frustration CDI and coding professionals have had with the lack of an index entry for “Type II MI” for the last several years.

Other classifications of MIs exist. There are five in total and among the new code proposals for “other myocardial infarction type” specifies types 3, 4 and 5 as inclusion terms.

End-stage heart failure

Another interesting suggestion for the CDC comes from its recommendation for a new code for end-stage heart failure I50.84, to be used in conjunction with other heart failure codes. This represents potential for assignment to a higher level of severity within both the APR- and MS-DRG systems. There are also new inclusion notes for end-stage heart failure to be reported for the American College of Cardiology (ACC) stage “D” if the physician only writes “stage D heart failure,” it can be coded as end-stage heart failure. Furthermore, new inclusion terms direct the coder that diastolic heart failure and diastolic left ventricular heart failure include heart failure with preserved ejection fraction or with normal effusion. The same goes for systolic heart failure and the term reduced ejection fraction. Additional new codes related to heart failure include:

  • Acute right heart failure (I50.811) with an inclusion term of “acute ISOLATED RIGHT HEART FAILURE”
  • Biventricular heart failure (I50.82)
  • High output heart failure (I50.83)

I was somewhat unfamiliar with high output heart failure so for now, this reference from the National Institutes of Health will have to do:

“The syndrome of systemic congestion in a high output state is traditionally referred to as high output heart failure. However, the term is a misnomer because the heart in these conditions is normal, capable of generating very high cardiac output. The underlying problem in high output failure is a decrease in the systemic vascular resistance that threatens the arterial blood pressure and causes activation of neurohormones, resulting in an increase in salt and water retention by the kidney. Many of the high output states are curable conditions, and because they are associated with decreased peripheral vascular resistance, the use of vasodilator therapy for treatment of congestion may aggravate the problem.” 

Surgical codes

The CMC proposed a number of updates related to surgical wound infections. There are several new proposals for obstetrics infection codes and there were also proposals for other wound infection codes, such as:

  • 41, infection following a procedure, superficial surgical site which accounts for a stitch abscess.
  • Deep incisional site under T81.42
  • Intra-abdominal abscess under T81.43
  • Slow healing surgical wounds, covered in the includes notes for T81.84, NON-healing surgical wounds per changes to the inclusion notes.

Additional recommendations

CMC has a few other suggestions CDI and coding professional need to note, such as:

  1. Moving late effects of cerebral vascular accident (CVA) from an Excludes I to an Excludes 2 category, which seems appropriate in light of Coding Clinic, Fourth Quarter 2016, p. 40, as well as the 2017 Official Guidelines for Coding and Reporting, advice to override the Excludes 1 note and code late effects when present in tandem with a new current stroke, anyway.
  2. A new code for immunocompromised status which includes terms for immunodeficiency status and immunosuppressed status, Z78.2. ICD-10 code Z78.21 covers immunocompromised status due to conditions classified elsewhere such as HIV or cancer, and Z78.22 immunocompromised due to drugs. In the past, immunocompromised status did provide for additional severity and it’s role in risk adjustment methodologies could expand.
  3. Proposed codes for the pediatric coma scale which could eventually provide some additional severity for cases with catastrophic neurological compromise. In this author’s opinion, these codes would be a welcome additional to pediatric hospitals seeking to properly adjust for their quality, outcomes and mortality metrics.
  4. Codes for nicotine dependence via electronic nicotine delivery systems (e-sigs, anyone?).
  5. Proposals for alcohol abuse, in remission. Also noteworthy, the term “Alcohol use disorder” seems to fall under the codes for alcohol dependence per newly proposed inclusion terms. The same proposals are provided for opioid abuse, in remission as well as cannabis, cocaine, sedatives, etc.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at For information regarding CDI Boot Camps, click here. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Q&A: Finding focus for CC/MCC reviews


William Haik, MD, FCCP, CDIP

Editor’s note: William Haik, MD, FCCP, CDIP, director of DRG Review, Inc. answered the following questions in conjunction with his webinar, “FY 2017 ICD-10-CM CC/MCC List with Revisions: Clinical Indicators and Query Opportunities.” To purchase the on-demand version of the webinar, click here. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Q: I’m having trouble with querying physicians for complication codes. Could you please provide guidance?

A: This is difficult. Unless there is an (coding) index directive, query the attending physician to determine if a condition occurring after surgery is due to, or caused by, the surgical procedure (such as atelectasis following surgery). From a medical perspective, the conditions which occur after surgery are not typically due to the surgery, but are due to other factors such as in atelectasis, operative pain, sedation, supine position, etc. Therefore, when I ask, it is when there is a high probability of being related to the surgical procedure (hematoma, excess hemorrhage which is addressed intraoperatively or immediately post-operatively). 

Q: Does systemic inflammatory response syndrome (SIRS) with pneumonia qualify for sepsis or should this be queried?

A: Unfortunately, in ICD-10-CM, there is no coding index entry for SIRS, and the previous index entry in ICD-9-CM for SIRS with infection no longer leads to sepsis. Therefore, the physician must be queried to clarify the documentation and assign an appropriate code.

Q: Should we query when the physicians use accelerated or malignant hypertension (HTN) in regards to hypertensive emergency/urgency?

A: Yes, as the former terms now are considered unspecified, a more specific condition should be sought.

Q: Would a physician query be necessary if the physician documentation indicates malnutrition (CC) and the dietician’s assessment documents mild to moderate malnutrition (CC)?

A: It is unnecessary to query a physician regarding the non-specific documentation of malnutrition. If the physician documents mild or moderate malnutrition, one would assign malnutrition, not otherwise specified, unless the physician specifies further.

Q: Do you have any suggestions for what CDI professionals should do if the physician documents a diagnosis but it is not supported by documentation in the chart or by clinical indicators?

A: I would ask the physician to review the record along with enclosed medical criteria regarding the condition in question. I have developed a handbook which provides evidence-based clinical indicators for common medical conditions. (For a copy, email

Q: Should we query for electrolyte abnormalities on gastric bypass patients. We are told imbalances are normal due to diet restrictions.

A: Although electrolyte disturbances are common in gastric bypass patients, they are not normal and not integral to the procedure. The physician would typically would treated the patient if the levels were significantly clinically deranged. In this setting, I would query the attending physician to determine if the levels are merely lab abnormalities or if they should be clinically significant and reportable.

Q: When acute respiratory failure is reported in the postop period and is integral to the procedure (for example, the patient remains on mechanical ventilation for less than two days following post op), do we have to query to see if it is significant or should we code without a query?

A: From a clinical perspective, I assume major surgery (cardiopulmonary, esophageal, gastrointestinal resection surgery) often require prolonged ventilation. In minor surgeries, such as prostate biopsies, extremity surgeries, etc., if the patient is on mechanical ventilation longer than 24-hours and assuming the patient is awake, then I would tend to query regarding post-operative respiratory failure, particularly if there is a medical complication such as aspiration pneumonia, pulmonary edema, etc.

Q: What’s the difference between acute respiratory failure and acute pulmonary insufficiency? Would oxygen dependent Chronic Obstructive Pulmonary Disease (COPD) be insufficiency instead of failure?

A: Acute respiratory failure is a life-threatening condition which is typified by a pO2 of less than 60 on room air (in patients with previously normal lungs) in the clinical situation of a patient with rapid respirations and increased work of breathing in the acute setting. Acute pulmonary/respiratory insufficiency is a poorly defined term merely meaning non-life-threatening impairment of gas exchange. Therefore, it does not represent a pO2 of less than 60 (in patients with previously normal lungs), but not a completely normal pO2. Oxygen-dependent COPD is consistent with chronic respiratory failure as to obtain oxygen (via Medicare) one must have a pO2 of less than 60.

Q: Post-operative pulmonary insufficiency is an MCC, but post-operative respiratory insufficiency is neither a CC/MCC. Is there a way to differentiate these two diagnoses?

A: There is no medical differentiation between pulmonary and respiratory insufficiency. This is merely an idiosyncrasy of ICD-10-CM.

Q: According to resources, a lactate less than 1.0mmol/L, which is normal, is considered a sepsis indicator. Why is this an appropriate indicator if it is within normal limits rather than greater than 2 which is abnormal?

A: Despite the “normal” limits of lactate up to 2.2 in most hospitals, it has been determined, retroactively, a lactic acid level of greater than 1 is a finding seen in sepsis. It is not specific as there are other hypoperfusion states and/or chronic liver disease which may result in an elevated lactic acid level. Therefore, it must only be interpreted in the appropriate clinical circumstances.

Q: Is healthcare associated pneumonia (HCAP) synonymous with hospital acquired pneumonia?

A: They are similar, but not synonymous. HCAP includes nursing homes, long-term acute care facilities, chemotherapy, and dialysis centers. Hospital-acquired pneumonia requires a hospitalization of at least a three-day stay. The pathogenic organisms are similar as is the treatment.

Book Excerpt: Teamwork makes the dream work


Elizabeth Lamkin, MHA, ACHE

by Elizabeth Lamkin, MHA, ACHE

CDI specialists do not work alone. They form a team with case management (CM) and physicians for concurrent documentation analysis and improvement. The case manager advises the physician on patient status, the CDI specialist ensures the documentation reflects the status and care, and the physician advisor is there to support CM and CDI if there is conflict with a physician or clinical staff. The physician advisor can take advantage of every interaction to transform potential conflicts into teaching opportunities.

For example, a patient is scheduled for surgery as an outpatient but the surgery is on the inpatient-only list (CMS, OPPS final rule, 2016). The surgery scheduling department checks the inpatient-only list and notifies the physician that CM is going to review for status. The surgery department then alerts registration, which notifies the CM, who checks to make sure all requirements for the inpatient surgery are met. The CM advises the physician on correct status and, ideally, the physician follows the CM’s advice.

The CDI specialist checks the documentation for compliance and coding, and queries the physician if the documentation is incomplete. If the surgeon refuses to change or complete the documentation, the CDI specialist escalates the issue to the physician advisor. The physician advisor contacts the physician and explains the reasons for inpatient status and additional documentation. The surgeon completes the documentation as requested. If these steps are completed, coding and billing will clearly know what claim to drop without requiring a bill hold and clinical review.

Additionally, this three-part team of CDI specialist, CM, and physician advisor are able to gather real-time feedback on whether the electronic health record (EHR) is user-friendly, and report findings back to the executive team and IT. In some cases, problems with the EHR are simply user error or lack of training, and the CDI specialist can play a role in teaching providers to use the EHR.

Throughout this process, the HIM department works with CDI and supports physicians through functions such as timely transcription and ensuring chart completeness. Together, CDI and HIM look to ensure appropriate orders, signatures, and all required elements of the medical record. This includes ICD-10 coding and documentation to monitor ICD-10 compliance. HIM has traditionally been responsible for the organization of the medical record but now must have a collaborative relationship with IT and the EHR vendor to ensure the record works well for all stakeholders.

Finally, HIM will also review the medical record upon discharge for completeness. The next step is to code the record for payment. If all the previous steps in revenue cycle have occurred correctly—required forms are in place, patient status is clearly documented with a care plan, and discharge status is clear and accurate—then the coders should have all the elements needed for accurate coding. There should be very few physician queries from HIM if coding is clearly supported through documentation. Getting all of this right while the patient is in the hospital will facilitate accurate coding and produce a clean claim to avoid back-end corrections and delayed billing.

Editor’s note: This article is adapted from The Revenue Integrity Training Toolkit by Elizabeth Lamkin, MHA, ACHE. Lamkin is CEO of PACE Healthcare Consulting and specializes in system development, quality and billing compliance. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Guest Post: Postoperative complication coding and value-based purchasing

by Ghazal Irfan, RHIA

Achieving compliant coding

Postoperative complication coding guidelines continue to cause difficulties for coders and CDI professionals. So, let’s analyze the steps needed to ensure complete, accurate, and compliant coding.

The first step in compliance is defining a postoperative complication. In general, a postoperative complication is an unanticipated outcome (in the form of a condition or a disease) that develops following an illness, treatment, or procedure.

For example, a 60-year-old female comes in for a herniorrhaphy (hernia repair). She has a past medical history of hypertension and morbid obesity with body mass index greater than 40. She smokes and has chronic obstructive pulmonary disease (COPD). Surgery goes well; however, post-surgery, the patient has a hard time weaning off of the ventilator and is immediately given inhaler treatments and placed on BiPAP. After a couple of incentive spirometry sessions and inhaler treatments, the patient feels better, and she is discharged home the following day.

The body of the operative report documents the patient’s inability to breathe on her own due to “acute respiratory insufficiency following extubation.” The header of the operative report, however, documents no complications. How should acute respiratory insufficiency following extubation be coded? Should it be coded as a “postoperative complication,” or as an “acute respiratory insufficiency?”

The ICD-10-CM Official Guidelines for Coding and Reporting states that “code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in.”

The Guidelines go on to explain that “it is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification if the complication is not clearly documented.”

Keeping these rules in mind, a coder cannot report the diagnosis as a postoperative complication due to the legal ramifications of these codes, and due to the conflicting documentation: acute respiratory insufficiency following extubation versus no complication.

When to query

While deciding on a secondary diagnosis, coders and CDI specialists need to ask questions like:

  • “Was the condition clinically evaluated, tested, and treated?”
  • “Did the condition result in extended length of stay?”
  • “Did the condition require increased nursing care?”

Patients who are smokers with COPD and morbid obesity have a hard time clearing their lungs of carbon dioxide and need a little help to get the gas exchange going. Since a coder/CDI specialist is not a doctor and cannot assume a cause-and-effect relationship, the coding guidelines will direct them to query the physician regarding postoperative complication.

The following query form can be used for any postoperative complication clarification and should be made part of the legal medical record.


Chances are, an inexperienced coder will look at the operative report, assign the postoperative complication code as not present on admission (POA-N), and drop the chart. Such an assignment negatively affects the facility’s quality outcomes report since postoperative complication codes with POA N are counted as the Agency for Healthcare Research and Quality’s patient safety indicators. A seasoned coder/CDI specialist, however, would submit a query and ask for clarification. Accurate, complete, and compliant coding can only be achieved when coders and CDI specialists have leadership support and physician buy-in. Coders need education on the significance of reaching out to physicians when coding postoperative complications, and when documentation is conflicting or inconsistent, even though the DRG stays the same.

Also, managers should not penalize coders for holding charts or failing to meet productivity benchmarks when pursuing a clarification. Code assignment affects reimbursement, quality outcome reporting under the VBP program, and academic research programs. Working collaboratively—coders, CDI professionals, and physicians—can assist facilities in gathering the most complete and accurate data sets, which will result in valid, ethical, and reliable quality outcomes reporting.

Editor’s note: This article originally appeared in JustCoding. Irfan is the coding compliance manager of hospital services for RevWorks AH-Corp and works with her team to ensure revenue cycle compliance. She holds a degree in health information management and is pursuing a master’s degree in biomedical informatics at Oregon Health and Science University. Opinions expressed are that of the author and do not represent HCPro or ACDIS.

Note from the Associate Director: Thanks for the memories—see you in Chicago for Outpatient CDI!

By Rebecca Hendren

And just like that, three days of education, network, and frivolity have come to an end. This year’s ACDIS Conference was our biggest and best yet. We were excited to celebrate our 10th anniversary with some extra Vegas sparkle and a chance to reminisce over how ACDIS—and the whole CDI profession—has grown over the last 10 years.

Some of the highlights for me were, as always, meeting so many dedicated CDI professionals and seeing the amazing connections that developed between you all. It warms my heart to see folks pour out of a session and stand chatting in hallways about the information they just learned, or huddle over laptops on the floor as they share best practices.

Thank you to the individuals who participated in the various focus groups held during the conference. The conversations had in those rooms and the perspectives shared will be considered over the next weeks and months and result in process improvements or new product development. A direct result of us coming together for four days of learning.

It wouldn’t be the ACDIS conference without plenty of laughs. Laurie Prescott and Shannon McCall did not disappoint as they reenacted the Family Feud gameshow to teach us the value of interdepartmental communication and not a few solid tips for both new and seasoned CDI professionals. We all had a chuckle at Brian Murphy’s cheesy jokes during the Meet ACDIS session where we discussed all the things ACDIS does and the many benefits of membership.

And all of you made me laugh every day with the good humor with which you tackle such complicated topics that have incredibly important results. ACDIS attendees have the most positive attitudes and can-do spirit of any group of professionals I’ve ever engaged with. It is heartening and inspiring and I know you are all returning to your workplaces with renewed pep and vigor, just like I am.

Finally, I hope to see many of you in Chicago in September for our inaugural ACDIS Symposium: Outpatient CDI. Join us for two days of education and networking dedicated to the fastest growing area of CDI: the outpatient setting. We’ll have two concurrent tracks with diverse sessions for both leaders/managers and clinical chart reviewers, including how to get started in the ambulatory setting, query techniques and nuances, metrics and analytics, staffing training, and demonstrating return on investment.

We hope you join us for two days of actionable strategies and unparalleled networking. All with the distinct ACDIS flair that you know and love!

Editor’s note: Hendren is the Associate Director of Product Development and Membership for ACDIS. Contact her at




Conference Corner: Thanks to our exhibitors and sponsors

ACDIS would like to take a few moments to recognize and thank all our sponsors and exhibitors of the 2017 10th annual ACDIS conference. Every year, our sponsors and exhibitors help us make the conference memorable. Thank you for helping us make the 10th annual conference the best yet!

The following is a comprehensive list of all our sponsors:

  • Title sponsor: MedPartners
  • Diamond sponsors: Optum360 (also sponsor of the 10th anniversary photo booth), Enjoin, TrustHCS, UASI
  • Platinum sponsors: 3M, Iodine, Sound Physicians Advisory Services
  • Conference specific sponsors: ChartWise, tote bag sponsor; Elsevier, welcome reception sponsor; HCTec, water bottle sponsor, The Claro Group, app sponsor; Harmony Healthcare, door cling sponsor

The following is a comprehensive list of all our exhibitors (in alphabetical order):

ACDIS Lee Health
Administrative Consulting Service (ACS) Libman Education
Addison Group M*Modal
American Health Information Management Association (AHIMA) Managed Resources Inc.
Altegra Health Solutions Maxim Healthcare Services
American Medical Association MedeAnalytics
BRG Healthcare nThrive
Brundage Medical Group Nuance
Caban Resources Ovation Healthcare Technology
CDI Search Group Oxford Healthcare Technology
CDIMD-ePreOP Peak Health Solutions
Chartwise Medical Systems, Inc. Pinson & Tang
ClinIntell, Inc. RecordsOne, LLC
ComforceHealth Saince, Inc.
Dolbey SCL Health
e4 SoftScript Transcription
Elite Medical Staffing Sound Physicians
ezDI Inc. Streamline Health Solutions
Feel Good Inc. Tenet Healthcare
GeBBS Healthcare Solutions Universal Coding Solutions
H3.Group Vincari
HCTec VitalWare
Huron Consulting Washington & West, LLC

Conference Corner: ACDIS honors achievement award winners at annual conference

ACDIS honored the nation’s top CDI professionals at its 10th annual conference in Las Vegas, Nevada, on May 10, including:

  • Nicole Kosiba, RN, BSN, CDI specialist at Advocate Health Care – Illinois Masonic Hospital in Chicago, with the Rookie of the Year award


    Nicole Kosiba, RN, BSN

  • Nicole Fox, MD, MPH, FACS, CPE, medical director of CDI and of pediatric trauma at Cooper University Health System in Camden, New Jersey, with the Excellence in Provider Engagement award


    Nicole Fox, MD, MPH, FACS, CPE

  • Fran Jurcak, MSN, RN, CCDS, director of clinical innovations at Iodine Software in Austin, Texas, with the Recognition of CDI Professional Achievement award


    Fran Jurcak, MSN, RN, CCDS

  • Rita Fields, BSN, RN, CCDS, regional CDI manager at Baptist Health in Louisville, Kentucky, with the 2017 CDI Professional of the Year award


    Rita Fields, BSN, RN, CCDS

ACDIS Director Brian Murphy presented the four awards in the morning’s general session to kick off the 10th annual conference. The awards were presented in front of an audience of more than 2,000 of the winner’s peers.

The Rookie of the Year award (a 2016 addition) recognizes the rapid growth of the CDI profession by awarding an outstanding CDI professional on the job less than two years at the time of nomination. The Excellence in Provider Engagement award (a 2016 addition) recognizes a professional who has made measurable impacts engaging providers (physicians, nurses, and others) in the need for accurate and complete documentation in the health record. The Recognition of CDI Professional Achievement award recognizes a professional who has made outstanding achievements within his or her facility, and the CDI Professional of the Year award is ACDIS’ top honor, given to a CDI professional who has made significant contributions within his or her organization and to the broader CDI community.

“We had a very impressive pool of candidates this year. The 2017 Conference Committee had some difficult decisions to make. But in the end they selected four winners who exemplify all the qualities that make for great CDI professionals—the initiative to step outside their comfort zones and advance the profession, the ability to lead others and lead by example, the willingness to work as part of a team with HIM/coding professionals, physicians, and others, and above all a passion for what they do and the CDI profession as a whole,” says ACDIS Director Brian Murphy.

“The hardest thing was that each of the nominees had done such tremendous work in their own respect, but there could only be one winner for each category. […] Just to be on that nominee list, you must have done something wonderful, but I’m very, very confident that people will agree with our choices. The work the winners have done has been stellar, to say the least,” says Faisal Hussain, MD, a member of the 2017 Conference Committee.

“It was really difficult, but I think the process went pretty smoothly. All of the nominees were excellent. It’s very difficult to choose because you hate to have to say no to anyone when they’re all so close to the top of the list. It was great to see the number of nominations, though. The people who supported the nominees put in so much work to do that!” adds Jeanne O’Connor, RN, MS, CCDS, another member of the 2017 Conference Committee.

To read more about the ACDIS Achievement Awards criteria, award descriptions, and selection process, click here.

Conference Corner: How to use the new ACDIS bookstore booth

Those who’ve attended multiple conferences may recall the previous ACDIS bookstore booth as a pretty hectic place, both for the attendees and the staff involved. With those memories in mind, the ACDIS team worked to redesign the booth for this year’s conference.

The booth has three distinct areas: one for browsing and asking questions, one for purchasing your books, and one to demo our e-learning courses and chat with our sales staff. This layout will streamline the experience of shopping at the booth for everyone involved.

Please take a few moments to review the following steps to ensure you know how the booth setup works.

  1. First, head over to the tables at the booth to browse the book and product selections. ACDIS team members will be present to answer any questions you might have.

    step 1

    Step 1: Choose your books

  1. After you’ve selected which books to purchase, head over to the checkout area. Once there, tell the staff member which book(s) you’d like. They’ll retrieve them from the bookshelves and you can pay right there.

    step 2

    Step 2: Make your purchase

  1. To demo a CDI e-learning course or chat with one of our sales reps, head on over to the final area of the booth.

    step 3

    Step 3: Chat with a sales rep and demo our e-learning

If you have any questions about the booth setup while at the conference, head on over. The staff is happy to help walk you through the process.