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.

Conference Update: Attendance proposal for the 10th annual ACDIS conference

Editor’s Note: CDI professionals wishing to earn support from program administrators to attend the ACDIS 10th Annual Conference may adapt the following proposal.

To whom it may concern:

I would like to attend the ACDIS conference in Las Vegas, May 9-12, 2017.

Understanding the limitation of our CDI program professional development budget, I want to outline why attendance represents a worthy expense.

The acdis conference offers a diverse range of sessions on the latest trends and techniques to enhance not just my own professional skills, but will afford me education I can bring back to our facility to share with our entire CDI program. The 2017 conference features more than two full days of training and education and networking opportunities, with five concurrent tracks featuring a diverse range of topics including best practices for staff management, physician engagement, clinically focused chart reviews, and critical regulatory updates to improve every aspect of our CDI department.

Here is a link to the conference webpage, which includes the complete agenda.

ACDIS always offers pre-conference events that we may also want consider including  a Risk Adjustment Documentation and Coding Boot Camp, another on Building a Best Practice CDI Team, and a third on The Physician Advisor Role in CDI.

The conference offers us an opportunity to meet and problem-solve with CDI experts. We can learn first-hand from the experiences of others which makes this an opportunity we cannot afford to miss.


Specifically, I want to attend the conference to get information or help with:

  1. <Fill in>
  2. <Fill in>
  3. <Fill in>

Here is an estimation of the cost to send me to the ACDIS Conference. The cost of conference includes the cost of some breakfasts and lunches:

Hotel: Three nights at $199*, for a total of $597 (hotels fill quickly so we should reserve as soon as possible).

*The hotel is charging a mandatory daily resort fee of $30 which includes access to the fitness center, Wi-Fi in the room, a daily newspaper, local and toll free numbered calls, and limited access to the business center including notary services and boarding pass printing.

Registration: $1,005 (early-bird discount is $905); ACDIS member $905 (early bird $805)

Airfare/travel is a cost I haven’t estimated.

I am requesting approval so we can take advantage of the early-bird registration rate of only $805 (if we’re ACDIS members) if we register before March 7, 2017. If we send the team, the fifth person registers for free (which we may wish to take advantage of).

If we are approved, we can further discuss which sessions might be best to attend to benefit our overall program. And, of course, we’ll meet after the conference to discuss significant takeaways, tips, and recommended actions to maximize our investment in our CDI program. I will also share relevant information with the team and other staff.

Thank you for considering this request. Again, if I get approval now, then we can save up to $200 on the registration, and keep our total investment to about $2,000. I look forward to your reply.

Thank you!



Note from the instructor: Increase understanding of pathophysiological concepts for CDI


Laurie L. Prescott, MSN, RN, CCDS, CDIP

by Laurie L. Prescott, MSN, RN, CCDS, CDIP

CDI specialists depend on clinical indicators to support queries. Hospitals and physicians need clinical indicators to support the validity of documented diagnoses.

Clinical indicators include patient presentation, symptoms and complaints, lab and diagnostic studies, and ordered treatments such as medications, interventions, monitoring, and assessments. You can find clinical indicators in the documentation of nursing and ancillary staff. As part of our work with clinical validation, all CDI specialists and coders have to work with providers to ensure diagnoses are well supported within the record. It is not enough to obtain documentation of a diagnosis; we must ensure the record clearly supports its presence.

To concentrate on these issues, we have developed a new boot camp to help increase understanding of pathophysiological concepts. The Mastering Clinical Concepts in CDI Boot Camp is designed to assist in the process of clinical validity reviews by examining a number of diagnoses common to both CDI and audit challenges. The Boot Camp discusses diagnostic interpretations, signs and symptoms, and common treatments and covers interventions to strengthen students’ knowledge and competence in record review.

These concepts will assist CDI teams in identifying vague or missing diagnoses regarding neuro, respiratory, cardiac, gastric, liver, musculoskeletal, endocrine, and renal diseases among others and increase staff confidence in speaking to providers and working to ensure adequate documentation in the record. During class, we use real-life scenarios to drive discussions about challenging CDI reviews and help our students:

  • Increase your understanding of key pathophysiological concepts
  • Improve the quality of clinical indicators used when you query
  • Cultivate critical thinking skills for use with data involving complex clinical concepts
  • Improve your ability to distinguish evidence-based clinical indicators from other data in the record

I’m looking forward to teaching this new boot camp aimed at experienced CDI professionals looking to advance their careers with next step training. This course is also valuable for coding staff who wish to increase their clinical understanding of the records they review.

We look forward to seeing you in class!

Editor’s note: Prescott is the CDI education director for ACDIS/HCPro. She is a frequent speaker and author of The Clinical Documentation Improvement Specialist’s Complete Training Guide.

Conference Q&A: Haik offers a clinical perspective on sepsis and respiratory failure

haikEditor Note: Over the coming weeks, we’ll take some time to introduce members to a few of this year’s ACDIS conference speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we’ve reached out to William E. Haik, M.D., F.C.C.P., C.D.I.P., who has practiced medicine in Fort Walton Beach, Florida since 1980, and will be presenting “Sepsis: 1, 2, 3 – RAC Attack! Respiratory Failure: Definition and Sequencing Guidelines.” He has received board certification in internal, pulmonary, and critical care medicine. Dr. Haik’s past professional accomplishments include: Chief of Internal Medicine, Director of Respiratory Care Services, Board of Trustees at his local hospital, President of the Okaloosa County Medical Society, and representative of the Government Liaison Committee for the American College of Chest Physicians. Dr. Haik’s coding background has included AHA’s Editorial Advisory Board and Expert Advisory Panel of Coding Clinic for ICD-9-CM as well as participation in the preparation of the original AHIMA CCS and CDIP examinations. He served on the original Board for ACDIS and aided in the preparation of the first certification examination. He currently serves as a final arbitrator for Medicare Part C MS-DRG modifications and as an expert consultant to the United States Department of Justice. He served on a multi-disciplinary committee which developed the 2010 and 2013 AHIMA Physician Query Practice Brief. Dr. Haik has conducted educational seminars and national teleconferences regarding physician involvement in DRG management, coding, and other related topics in association with HCFA (CMS), AHA, AHIMA, HCPro, and various state Quality Improvement Organizations. Since 1988, Dr. Haik has served as the Director of DRG Review, Inc., a physician directed hospital coding consultative service. The goal of DRG Review, Inc. is to educate medical and coding staffs in medical record documentation and coding compliance.

Q: As an MD, what do you bring to the CDI table that others don’t?

A: I think I bring a practical knowledge, a working clinical practice perspective. I have some coding knowledge as well, so I can merge the two.

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

A: Complete boredom! Just kidding! In all seriousness, attendees can expect to:

  1. Understand the clinical definition and coding nuances of acute and chronic respiratory failure;
  2. Understand the evolution of the definition of sepsis; and
  3. Understand how to apply the three different sepsis consensus statements and how, by understanding those, one can defend an adverse clinical documentation position from a RAC

Q: What is one tool CDI professionals cannot live without?

A: In my opinion, a CDI professional should have a few things in their toolkit. First, they should have a clinical background, a working knowledge of the coding clinics for ICD-10, a reference tool that answers certain clinical guide and their coding correlation.

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: We do arm wrestling during my talk! Just kidding. In reality, I’m trying to get them to think inside the box! I want to get everyone to think clinically as a physician would.

Q: What are you most looking forward to about this year’s conference?

A: It is in Las Vegas, need I say more? Seriously, though, I’m looking forward to hearing some presentations on quality – HCCs, VBP – such as that. I’m really looking forward to expanding my knowledge.

Q: Fun question: do you have any pets?

A: Her name is Mary-Kate – she’s my wife. Just kidding. Actually, I don’t have any pets right now. I have had three dogs, though. They were named Bitey, Gus, and Tucker.

Radio Recap: CDI productivity

ACDIS radio


ACDIS surveyed more than 400 CDI professionals about their facility productivity expectations and published a white paper on the topic in the fall. Tamara A. Hicks, RN, BSN, MHA, CCS, CCDS, ACM, director of clinical documentation excellence for Wake Forest Baptist Health in Winston-Salem, North Carolina, and Judy Schade, RN, MSN, CCM, CCDS, clinical documentation specialist for Mayo Clinic Hospital, discussed their experiences, illustrating the same basic findings as paper during the December 28, 2016, episode of ACDIS Radio.

At Wake Forest Baptist Health, CDI review at least 90% of their total daily admissions, Hicks said. At Mayo Clinic, they aim for 100% of all Medicare admissions, Schade said. Both facilities also monitor other aspects of the CDI process, such as query response rates and query agree rates, but there are no set expectations because those numbers vary drastically on a day-to-day, case-by-case basis.

As far as the chart review expectations, Hicks and Schade also had slightly different answers. According to Schade, CDI specialists should review between eight and 10 new reviews per day. After that point, CDI specialists should complete re-reviews every two-to-three days depending on the original review. Hicks expects a total review number between 20 and 25 cases, with five to 10 of those being new reviews. Although Hicks set out more stringent total review expectations, Hicks and Schade agreed that a max of 10 new reviews was a reasonable expectation. According to the white paper study, the average for total reviews is between 16 and 20 per day, in line with Hicks’ and Schade’s comments.

As CDI expectations evolve, CDI programs may have many competing initiatives. The new white paper attempts to “identify a lot of variables” regarding what affects staff productivity rather than provide strict expectations regarding national averages, said Schade.

Nevertheless, some common themes exist. “One major variable is whether the medical record is paper or electronic. Paper charts mean CDI staff have to incorporate travel time to the nursing units into their productivity, while the electronic medical record enable the CDI staff to stay at their desk,” Hicks said.

The goal and focus of the review represents another big variable. “If staff are only looking for CCs and MCCs, they can probably review more records than, say, a CDI specialist who’s reviewing for MS-DRG assignment, hospital-acquired conditions, patient safety indicators, and severity of illness/risk of mortality. That’s going to take them longer,” Hicks said.

Experience and skillset also play a huge determining factor in overall productivity, according to Schade. “ICD-10 presented many, many challenges with diagnoses and procedure codes, so specializing has assisted in accurate and complete document coding and also providing a resource to coding,” Schade explained with regards to the Mayo Clinic’s model. According to the white paper, experience level was the largest variable (54%) to CDI productivity.

Hicks also indicated that other responsibilities influence a CDI specialist’s productivity. Technology, however, has also made it possible for CDI specialists to review files quicker and more efficiently than before. At Mayo Clinic, they combat the effect of other responsibilities by “performing 100% of reconciliation—that’s after coding and before billing—on all the records that were reviewed concurrently,” Schade said. This brings about a “complete and accurate view of the patient” at the end of the day.

With outpatient CDI—a relatively new area—Wake Forest is only reviewing the “raw number of cases reviewed,” Hicks said. Additionally, at the current stage, the process is very manual. Wake Forest hopes to develop technology to both improve efficiency and track the success of the program. Mayo Clinic is in the early stages of developing an outpatient CDI program as well, Schade said. She recommended that other facilities looking to incorporate outpatient CDI programs do some research on the ACDIS website, as that has helped Mayo get things started.

When it comes to CDI productivity standards, “there are so many variables that impact each individual CDI program and that was really reflected in the survey results [in the white paper],” Schade said.




Guest post: Querying for clinical validity

by Erica E. Remer, MD, FACEP, CCDS

Some clinicians may interpret a query as an affront to their clinical judgment. This is not your intent. You are trying to determine whether a condition was present and whether it should compliantly be coded or not.

Here is an example of how a coder would provide the clinical indicators in the affirmative for the clinician to answer the query in regards to an intimated diagnosis:

Dear Dr. So and So,

The SCr was 3.4 and two days ago it was 1.4. You documented “renal dysfunction likely due to contrast.” Is there a diagnosis that corresponds to this?

You can also provide the physician with the documented diagnosis and the clinical indicators which make you skeptical:

Dear Dr. So and So,

You documented that this patient had pneumonia in the history and physical assessment. Over the course of the next three days, the repeat chest x-rays were read by the radiologists as “no infiltrate,” the sputum and blood cultures did not grow any organism out, and antibiotics were discontinued. However, the impression list continues to list “pneumonia.” Based on this information, please confirm the patient’s condition and your medical decision making, clinical support for the diagnosis in the medical record. If pneumonia was ruled out, please amend the assessment and plan, diagnosis list.

If a physician advisor supports the coding and CDI departments involve him or her in the process. The physician advisor can help create internal clinical guidelines to help providers ward off CVDs by standardizing criteria.

Make sure your providers see coders and CDI professionals as an ally, not an adversary, and that goal of CDI efforts is to protect both the physician and the facility from unnecessary denials.

Become educated

The last step is education—both for the CDI staff and for the physician.

Physicians often don’t know about clinical validations denials. When they occur, share them with providers. Point out what could have prevented them. Reinforce the good habit of documenting their thought process and explaining why they are doing what they are doing to and for the patient. Don’t accept responses to queries with only diagnoses and no clinical evidence supporting them.

Educate CDI and coding teams. If you have regular staff meetings, you can discuss topics which seem to be eliciting clinical validation denials. Changing clinical criteria may herald impending denials. Crowdsource best approaches to specific clinicians and specific conditions. Have joint discussions between coders and the CDI staff.

Clinical validation denials require time, energy, and resources to revisit patient encounters coded in the past. Concurrent clinical validation practices can prevent future denials by shoring up clinical support of valid diagnoses and eliminating others. An ounce of prevention is worth a pound of cure.

Editor’s note: This article, written by Erica E. Remer, MD, FACEP, CCDS, founder and president of Erica Remer, MD, Inc., Consulting Services, first appeared in its entirety, in JustCoding. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Contact her at



Local Chapter Update: TN leadership recaps successful January event


The joint meeting of ACDIS, THIMA, and THA

by Sherri Clark, BSN, RN-BC, CCDS, CCS, Clinical Documentation Nurse Specialist at the University of Tennessee Medical Center in Knoxville, and core member of the Tennessee chapter of ACDIS

The joint meeting of the Tennessee Chapter of ACDIS (Association of Clinical Documentation Improvement Specialist), THIMA (Tennessee Health Information Management Association), and THA (Tennessee Hospital Association) occurred on January 27. The meeting took place at the THA headquarters in Brentwood. The subject of the meeting was “The Impact of ICD-10 and Payment Reform on Clinical Documentation Improvement.” Four members of the core team of TN ACDIS chapter leaders (Sherri Clark, Kristie Perry, Cynthia Raymond, and James Kennedy, MD) and one chapter member (Kyra Brown) served on the planning committee for this joint meeting. Attendees were offered a number of hour-long presentations to choose from during the meeting, including:

  • Managing Conflicting Guidelines in ICD-10–CM/PCS
  • CDI, Coding, and Quality – The Three Legged Stool
  • Payment Reform in TN – Health Care Innovative Initiatives
  • Recovery Auditor Prevention Strategies: How to keep the predators away
  • MACRA, MIPS, APMS: Why CDI is a critical ingredient of the alphabet soup?
  • ICD-10-PCS and the Impact on CDI
  • The Case for Category II Codes
  • Hospital Improvement Network and other statewide databases: How are they used and the importance of quality data
  • The Impact of HCCs on Physician Accountability

The meeting drew physicians, coders, CDI specialists, and executives from THA. The presenters for the meeting included members of ACDIS, AHIMA, THIMA, and the THA. ACDIS Director Brian Murphy attended the meeting, as did all of the TN ACDIS Chapter leaders—Sherri Clark, Kristie Perry, Cynthia Raymond, Judy Rochelle, and James Kennedy. The joint meeting qualified for six continuing education units for ACDIS and AHIMA.

Editor’s note: Clark is a Clinical Documentation Nurse Specialist at the University of Tennessee Medical Center in Knoxville, Tennessee. She has been an ACDIS member since the spring of 2008 (she even attended the first ACDIS conference that year!) and a chapter leader since 2011 when the chapter was formed. For information regarding upcoming local chapter events, visit the website or email Clark at

Conference Q&A: DeVault illuminates the shift to outpatient CDI


Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA

Editor’s Note: Over the coming weeks, we’ll introduce a few of this year’s speakers who are heading to the podium for the ACDIS 10th Annual Conference which takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we talked with Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA, manager, HIM Consulting Services for United Audit Systems, Inc., who presents “Clinical Documentation Improvement – From Inpatient to Outpatient: Defining the different documentation, coding, and reimbursement requirements.” She has more than 25 years of experience in HIM serving as the senior director of HIM practice excellence, coding and reimbursement for AHIMA from 2008 to 2014.

Q: What made your company want to expand into the outpatient setting?

A: We noticed that it was the next natural progression in the CDI world. With hierarchical condition categories (HCCs), Medicare Access and CHIP Reauthorization Act (MACRA), risk adjustment, etc., it’s really a prime time for CDI. Where to start is the hard part. With inpatient documentation reviews, CDI professionals have a captive audience, so to speak. With outpatient, CDI programs need to look at all the different departments where physician documentation plays a role. On top of that, there’s the physician clinics. It’s very complex on how you move the well-oiled machine of inpatient CDI into the outpatient world – everything gets really muddied.

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

A: At the end of my session, attendees will be able to:

  1. Start to delineate what outpatient CDI looks like in the post-acute care setting. It’s not as simple as duplicating your inpatient CDI program
  2. How inpatient and outpatient CDI roles differ; and
  3. Some tools to build the framework for outpatient CDI. Your CDI framework could look very different and you need to do active discovery. CDI looks different in every setting based on where their needs are.

Q: Who should attend your presentation and why?

A: CDI specialists and anyone who’s involved with coding and CDI – CDI managers, finance side, directors, HIM directors, coding managers, coders, and even physicians! Essentially, it would be good for everybody. Anybody trying to figure out what outpatient CDI looks like should definitely attend. It’s like the transition to ICD-10 in that we need to think about how we eat the elephant one bite at a time. Outpatient CDI is a whole new elephant.

Q: What’s one tool no CDI professional should be without?

A: A CDI specialist should always have their communication skills. A CDI specialist is in a unique position because they live in the middle. They need to have a relationship with providers and then they also need that communication with coders.

Q: What are you most looking forward to about this year’s conference?

A: Networking! Last year, was the first year I was there as a vendor. It’s so fun to meet our clients. It’s great to put a face to a name!

Q: Fun question: what’s your favorite movie?

A: I’m kind of a sap, so I love PS. I Love you. I also really love Brian’s Song.




Guest Post: Clinical validation denial targets

by Erica E. Remer, MD, FACEP, CCDS

Auditors target multiple conditions which for clinical validation denials (CVD). Personally, I found acute kidney injury (AKI) and malnutrition the most commonly defensible targets. On the other hand, I often agreed with auditors on their CVDs for pneumonia and urinary tract infections. Other frequent CVDs included sepsis, encephalopathy, and respiratory failure.

Certain diagnoses are susceptible to CVDs for the following reasons:

  • DRG downgrade: Auditors target medical records with only one CC/MCC because doing so downgrades the DRG and results in less reimbursement.
  • Empiric treatment: Providers start antibiotic therapy early for patients who present with signs of infection (e.g., fever, leukocytosis, altered mental status) on as they seek the infection’s source. Sometimes the physician cannot identify the source or the etiology of the disease turns out to be a different than originally expected. Clinicians also need to be careful to not propagate the original debunked diagnosis via copy and paste, so it gets wrongly coded.
  • Documentation consistency: Physicians should document their medical decision making process throughout the patient’s stay. Best practice is to document when a diagnosis is initially considered (may be in uncertain format), when the diagnosis is definitively ruled in, and when the condition resolves. The physician should recap this information in the discharge summary. Only mentioning a diagnosis once in the medical record, while permissible, raises an auditor’s interest and begs the question of whether the condition really was present.
  • Pursuant to a query: When providers need to be queried to make a diagnosis codable, and they agree without supplying any clinical support, a red flag goes up—and I mean like waving one in front of an auditor like a bull, and not just signaling peril up ahead.

Finally, auditors target diagnoses with uncertain or emerging clinical guidelines. Clinical guidelines change, but it takes time for medical practice to adjust (e.g., malnutrition, sepsis). If a guideline is not universally adopted (for example, discussions regarding the new Sepsis-3 definitions) some variability in medical practice is allowed. That doesn’t necessarily mean a provider is wrong if he or she does not follow the latest guideline. As long as the provider is within the acceptable range of practice, he or she just needs to demonstrate the clinical considerations of the case and the auditor should accept the diagnosis. If a provider deviates from clinical criteria or guidelines, he or she should document the mitigating circumstances (e.g., on beta-blockers, previous antibiotic therapy, contamination).

On the other hand, the provider needs to consider established guidelines. If the average, prudent similarly qualified practitioner wouldn’t call an asymptomatic deviation of sodium by 1 mEq/L, hyponatremia, neither should you.

Similarly, AKI has criteria of change within the previous 48 hours, or deviation from a baseline from seven days ago, but a provider could make a convincing argument that the patient’s serum creatinine (SCr) is always X and the acute derangement is likely to have occurred since the onset of symptoms 36 hours ago. It would be quite serendipitous to randomly have a baseline drawn within seven days of an index visit if AKI preceded hospitalization, wouldn’t it? However, if the SCr is only off by 0.1 mg/dL, you are hard-pressed to spin that as AKI.

While the coder may not really the arbiter of clinical validation, coders should be empowered to refer questionable records for a clinical review either by the CDI specialist, the attending, or a physician advisor/champion, and coders need to know which conditions are vulnerable and which clinical indicators to consider.

Absence of abnormal clinical indicators does not mean the condition is definitively not present; it means the encounter needs clinical review and the condition may require more documentation to support it.

Editor’s note: This article, written by Erica E. Remer, MD, FACEP, CCDS, founder and president of Erica Remer, MD, Inc., Consulting Services, first appeared in its entirety, in JustCoding. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Contact her at For the third part of this article, return to the blog next week!

Note from the Instructor: Are you a critically thinking CDI?


Laurie L. Prescott, MSN, RN, CCDS, CDIP

by Laurie L. Prescott, MSN, RN, CCDS, CDIP

I spend much of my time communicating with CDI managers and directors. They work tirelessly to develop and nurture CDI departments, focusing much of their time on training new CDI staff and evaluating the experienced CDI professionals in their care in order to identify areas of education need. Often CDI directors fight for funding to buy the newest software with the latest and greatest bells and whistles. I remember how excited I was to use the new encoder when I was a young CDI specialist. Now there’s computer assisted coding software, software that prioritizes and develops work lists, tracking software, query opportunity software, etc., etc.

This all sounds great, but I think such technology may also be a hindrance when training new staff.

Experienced CDI specialists often complain about the lack of critical thinking skills within the ranks of those new to the industry. I often hear that it is difficult to teach a new CDI staff person because “no one uses the books anymore.” I hear that new CDI staff simply follow the query leads fed to them from the software programs and that they are not thinking for themselves. Managers also complain that many of the more experienced staff seem to be “coasting in their retirement job,” don’t wish to engage with the medical staff or challenge the status quo, and have become overly dependent on the EHR and the software to direct their day-to-day activities.

Please don’t get me wrong, I love the technology we have at our fingertips, but we also must understand that we, the CDI specialists, should be directing the software and not the other way around. This technology is meant to be a tool that assists the living, breathing, thinking CDI specialists. We need to use the skills our experience and intellect bring to the table whether those abilities be regulatory or coding knowledge, clinical expertise, communication skills, or, more importantly, a collection of these talents.

We speak about software in our CDI Boot Camps all the time. In these discussions, I encourage new CDI staff to pick up a code book, and a DRG Expert, and work the chart the old-fashioned way. Many groan when I mention such prehistoric methods to practice CDI, but there is a method to my madness. To effectively work as a CDI and to use the technology to its utmost value, we need to understand the inner workings and decisions the software program was designed to make. We need to know when the software misses something or inappropriately identifies a diagnosis that does not exist.

Critical thinking is defined as an active process of applying, analyzing, synthesizing, and evaluating information. The Critical Thinking Community ( describes it as “ entailing the examination of those structures or elements of thought implicit in all reasoning; purpose, problem, or question-at-issue; assumptions; concepts’ empirical grounding; reasoning leading to conclusions; implications and consequences; objections from alternative viewpoints; and frame of reference.”

My simplified definition is that critical thinking is “thinking about your thinking,” questioning all conclusions and working to ensure you interpret all the facts and evidence correctly.

Critical thinking has been a buzz word for years, especially in healthcare. Many go through the motions of the day, not taking the extra energy to actually think through the record and identify those opportunities requiring intervention. CDI professionals need to attack each day’s tasks with an active focus. We cannot simply depend on a computer program to do the job for us. If all it took was a computer program, no thinking, no experience no effort—we would not be such a hot commodity in the world.

Editor’s note: Prescott is the CDI education director for ACDIS. She serves as a full-time instructor for its various Boot Camps as well as a subject matter expert for the association. Prescott is a frequent speaker on HCPro/ACDIS webinars and is the author of The Clinical Documentation Improvement Specialist’s Complete Training Guide and co-author on the forthcoming volume regarding the role of CDI staff in quality of care measures. Contact her at This article originally appeared in CDI Strategies.

Guest Post: Protecting documentation from clinical validity denials

by Erica E. Remer, MD, FACEP, CCDS

Clinical validation denials (CVD) result from a review by a clinician, such as a registered nurse, contractor medical director, or therapist, who concludes, retrospectively, that a patient was not really afflicted by a condition documented in the medical record and coded by the coder.

If a coder assigns a code for a condition not really present, and removing that code assignment results in a lower-weighted DRG, then it is reasonable for a payer to expect the overpayment back.

However, if the condition was indeed present, medical personnel invested time, energy, supplies, and other resources, the hospital is entitled to reimbursement. Therefore, it is not appropriate to remove a diagnosis which was genuinely present. It is also unfair to remove legitimate diagnoses, because this results in the downgrade of severity of illness and complexity of management, and falsely deflates the quality measures assigned for that patient’s care.

Thorough documentation

It has never been reasonable or compliant for a coder to infer medical conditions from clinical indicators, and it is not reasonable to expect a coder to decide that a condition doesn’t exist if the provider documented it.

The ICD-10-CM Official Guidelines for Coding and Reporting for 2017 states:

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient.

Although the provider’s statement may be sufficient to code a particular condition, it does not mean the condition indisputably exists.

The adage is, “if you didn’t document it, you didn’t do it.” But we all know that is not true. No physician documents every thought or action, and it would be absurd to expect them to do so. The dilemma arises when a physician documents a condition without giving adequate evidence as to what led him or her to make the diagnosis.

Concurrently, a documented diagnosis which is not really present could lead other healthcare providers down an erroneous path. Conversely, not providing clinical support for a valid diagnosis sets the stage for future denials.

The legal definition of the standard of care is managing a patient at the level at which the average, prudent, similarly qualified practitioner in a given geographic medical community, would be providing medical care under the same or similar circumstances. There are clinical guidelines and scores which may assist a clinician in making diagnoses, but prudent practitioners also bring their past experience, knowledge, and judgment into play.

Medicine is an art, not a science, and not every patient “reads the textbook.” Many patients’ lives have been saved by a clinician who followed his or her gut. Just because a patient doesn’t strictly meet clinical criteria, doesn’t preclude him or her from having the medical condition that an astute provider diagnosed.

Is there a standard of documentation similar to that legal definition of a standard of care? The purpose of patient record documentation is to foster quality and ensure continuity of care. It is clinical communication. The fallacy is that documentation needs to be expansive and long; it just needs to convey to the subsequent healthcare provider (as well as the coder, utilization/case manager, auditor, lawyer, etc.) what the provider was thinking and why.

What coders can do

Sensible, qualified, and experienced coders or CDI specialists may read documentation and have concerns that a diagnosis is not supported by the clinical indicators.

Do they just unfailingly code a documented condition because the Official Guidelines for Coding and Reporting say that the provider’s statement is sufficient, or do they query the physician? Which conditions are prone to this? What clinical indicators should they be considering? How does one broach this subject with the physician?

The ACDIS/AHIMA’s Guidelines for Achieving a Compliant Query Practice recommend generating a query when the health record documentation “provides a diagnosis without underlying clinical validation.” It notes that “the focus of external audits has expanded in recent years to include clinical validation review,” and instructs coders to follow CMS and Coding Clinic guidelines, and to “query the physician when clinical validation is required.”

The CMS Statement of Work for the Medicare Fee-For-Service Recovery Audit Program 2013 notes that “clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder.”

I concur that a certified coder who has identified a diagnosis which needs more clinical support does not have the ability to validate it, but has the skills to recognize the necessity for validation.

If your institution has CDI specialists, then you have someone with the appropriate credentials in place to generate a query. The physician is the one who performs the validation by responding to the query in the affirmative, and by providing their clinical evidence for the diagnosis in question.

Editor’s note: This article, written by Erica E. Remer, MD, FACEP, CCDS, founder and president of Erica Remer, MD, Inc., Consulting Services, first appeared in its entirety, in JustCoding. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Contact her at For the second part of this article, return to the blog next week!