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: Improving CDI-physician relationships

Experts agree that a collaborative healthcare environment leads to better patient outcomes and improved organizational success. Despite this, long-standing tensions between nurses, coders, CDI specialists, and physicians can be difficult to overcome.

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Note from the CCDS Coordinator: Is it time to recertify your CCDS credential?

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CCDS Coordinator Penny Richards

by Penny Richards

In the next couple months, hundreds of CCDS holders will need to recertify their credential. Even those who’ve gone through the process may need a quick refresher. So, without further ado, here are some tips and hints to help you have a smooth recertification process.

You may recertify up to 60 days before your due date. Not sure when it is due? Look at the date on your certificate (the one you have framed and hanging on the wall, of course). Your recert is due every two years from the date you passed the exam. You can also email me (prichards@acdis.org) and I’ll check your due date in the CCDS database.

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Tip: Diversify your CDI education to keep staff engaged

Every CDI specialist knows how difficult it can be to set aside a whole hour or more for dedicated training and education. With productivity expectations and quotas, cutting out a sizable chunk of time for learning can be challenging. Diversifying CDI education tactics can help engage staff in more meaningful ways.

Though electronic health records (EHR) and technology sometimes complicate the CDI process in select ways, CDI managers and leaders can harness technology to increase educational reach. [more]

Q&A: Denial management teams

Have CDI questions?

Have CDI questions?

Q: What guidance do you have for building a denial management team?

A: As with any team, it is important to have the right players working together with identified roles and responsibilities established for each. The members of the denials management team should be representative of departments with a direct tie to the various types of denials. Include the following groups: [more]

Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 2

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

By James Kennedy, MD, CCS, CDIP

Determine the underlying cause of the altered mental status

Remember that the various forms of altered mental states have underlying causes, which, if defined, diagnosed, and documented, accurately represent the patient’s condition for risk-adjustment purposes. Options include:

  • Neurodegenerative disorders. To the extent that it’s possible to state what the underlying degenerative brain disease is, please do so. Options include Alzheimer’s disease, Lewy-body dementia, late effects of multiple strokes, normal pressure hydrocephalus, some cases of Parkinson’s disease, and a host of others. Note: The term “multi-infarct dementia” requires additional documentation that it is the late effect of multiple strokes. Consider the word “encephalopathy” as well (see the next item) when documenting these underlying causes.

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Symposium Update: Early bird hotel discount ends August 17

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The ACDIS Symposium: Outpatient CDI is currently sold out!

There are only a couple more days left to get a discounted hotel room rate for the ACDIS Symposium: Outpatient CDI. Reserve your room by Thursday, August 17 to take full advantage of the discount. The symposium takes place from September 18-19 at the Hilton Oak Brook Resort and Conference Center in Oak Brook, Illinois.

When you book your hotel room by August 17, you’ll get the discounted room rate at the Hilton Oak Brook Resort and Conference Center for $159 (tax and fees not included). To book by phone, call 866-275-6295 and mention ACDIS.

Please note that the Outpatient Symposium is sold out. If you have registered and know you won’t be able to attend, please notify customer service to allow others into the event.

 

Note from the Associate Director: Announcing a new outpatient version of the CDI Pocket Guide

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Associate Director Rebecca Hendren

By Rebecca Hendren

Outpatient CDI is a fast-growing area of the profession. So, I’m excited to announce a new resource that will be an incredibly useful tool for those expanding to the outpatient arena. Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS, authors of the CDI Pocket Guide, are currently finishing their work on a new version focused on Hierarchical Condition Categories (HCC): the 2018 Outpatient CDI Pocket Guide!

One of our guiding principles at ACDIS is to be at the forefront of changes in the industry. We want to provide our members with guidance, information, and resources they can turn to for education and clarification as they venture into new CDI focus areas. We’ve been publishing articles exploring the growing outpatient and ambulatory arena for several years now and will continue to do so as this segment of the profession grows and changes. We want to keep our fingers on the pulse of what’s going on and share that knowledge with our members.

We bring together leading thinkers in the profession who can share their expertise, whether through articles in the CDI Journal, innovative sessions at our annual conference or the new outpatient-focused ACDIS Symposium, or lively discussions in the ACDIS Forum.

I’m delighted that the trusted authors of the CDI Pocket Guide are equally forward thinking and partnered with us to develop a this new resource.

Please continue to let us know what information you need and what resources you would like ACDIS to offer. We really do listen to you and use your feedback to develop our editorial directions.

Editor’s note: Hendren is the associate director of membership and product development at ACDIS. Contact her at rhendren@acdis.org.

Q&A: Coding chronic kidney disease, hypertension, and diabetes mellitus

LauriePrescott_May 2017

Laurie L. Prescott, RN, MSN, CCDS, CDIP, answered this question

Q: Let’s say a provider documented chronic kidney disease (CKD), 2/2 hypertension (HTN), and diabetes mellitus (DM), and the stage of CKD was not specified, but lab results show patient was in stage 2. Could I assign codes for CKD, stage unspecified, Hypertensive CKD w/ stage 1-4, and Type II DM. Do I need to assign a separate code for HTN?

A: Let’s break down the documentation.

CKD secondary to HTN and DM: With this documentation, we have two combination codes to assign—hypertensive CKD and diabetic CKD. We would also assign a code to reflect the stage of the CKD.

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Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 1

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

By James Kennedy, MD, CCS, CDIP

In ICD-10-CM, defining, diagnosing, and documenting the various forms of altered mental status and their underlying causes remains an ongoing challenge for physicians and their facilities.

Even the esteemed New England Journal of Medicine states that, “‘Altered mental status,’ a nonspecific term that is frequently used to describe alterations in alertness, cognition, or behavior, is commonly encountered in the emergency setting.” If you have a subscription or access through your medical library, review the discussion at www.nejm.org/doi/full/10.1056/NEJMcps1603154. [more]

Symposium Speaker Highlight: Whitley shares story of ambulatory success

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The ACDIS Symposium: Outpatient CDI takes place Sept. 18-19

Editor’s note: There are only 45 more days left until the first ever ACDIS Symposium: Outpatient CDI, September 18-19, in Oak Brook, Illinois. Last week, we brought you a Q&A with Laurie L. Prescott, MSN, RN, CCDS, CDIP, CRC, in CDI Strategies, but she’s not the only Symposium speaker we got to know recently. Today, we spoke with Yvonne Whitley, RN, BSN, CRCC, CPC, CRC, the supervisor for Novant Health Medical Group’s Ambulatory CDI team, who will present “Novant Health ambulatory CDI—How we’ve grown!” at the event. Please note that this event is filling up fast with limited seats remaining.

Q: Can you explain why you use the term “ambulatory” rather than “outpatient?”

A: The simple answer is that “outpatient” refers more to facilities such as wound care, same day surgery, infusion centers, etc. “Ambulatory,” on the other hand, refers to the provider clinics. Currently we only focus on the ambulatory setting.

Q: What was the biggest challenge you encountered during the implementation of your ambulatory CDI program?

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