Author Archive for Penny Richards

Note from the CCDS Coordinator: Over the Y92.838 and through the Y92.821 to Grandmother’s Y92.01 we go

CCDS Coordinator Penny Richards

By Penny Richards

Ah. Thanksgiving. While the ACDIS team will be out of the office for the Thanksgiving holiday and Black Friday, we know that the opportunities for mishaps requiring medical attention are far too plentiful to mention. We wouldn’t want to leave you without ACDIS’ guidance in this trying time, so here is a short list of codes that might prove helpful to the on-duty clinical documentation specialist. [more]

Note from the CCDS Coordinator: Happy birthday, ACDIS!

CCDS Coordinator Penny Richards

by Penny Richards

ACDIS and I are both celebrating our birthday this week. ACDIS is turning 10. I turned 10 a long time ago.

In 2007 (the year of ACDIS’ “birth”):

• Apple launched the iPhone
• Bob Barker appeared for the last time as host of “The Price is Right”
• “Harry Potter and Order of the Phoenix” debuted in theaters
• Helen Mirren won the Oscar for best actress for “The Queen”
• The Boston Red Sox swept the Colorado Rockies to take the World Series

In the year of my birth: [more]

Note from CCDS Coordinator: Do you really need the CCDS certification?

CCDS certification

I received an interesting question recently from someone contemplating Certified Clinical Documentation Specialist (CCDS) certification. She asked:

“I am wondering whether obtaining the certification gives the CCDS holders any special privileges? Are they able to perform duties that they otherwise would not be able to if they did not hold the certification (not by knowledge, but by law)?”

In my five-plus years with ACDIS no one has ever asked this question. Obtaining the CCDS credential does not give the holder any additional rights, privileges, or responsibilities. It does not legally empower the holder to perform any duties.

What the CCDS credential does, however, is recognize individuals who have an advanced level of CDI knowledge and who have the proven ability to work as clinical documentation specialists. Candidates for the CCDS designation are required to have at least two years of experience in the profession.

The CCDS demonstrates an accomplishment that captures both experience and knowledge in the field, and many facilities suggest or require their CDI staff hold the CCDS or earn it following the two-year minimum requirement to sit for the exam, after hire. Facilities often hire individuals with nursing (clinical) or coding experience for the clinical documentation team and train them to become proficient. It is the decision of the individual facility to determine who to employ as a CDI specialist and what responsibilities are given to individuals who perform the CDI role, which may differ depending on whether or not they hold the certification.

What I didn’t tell the writer is that, for a lot of people, CCDS certification is a matter of pride. In the fall of 2016, ACDIS conducted a survey of CCDS holders and asked them what they see as the value of their credential. Their responses included:

• The credential differentiates me as a leader
• I am set apart as the CDI who went the extra mile to prepare for and achieve the certification for my very specialized profession
• I am the go-to-person for others to come to with questions for assistance
• The credential demonstrates that I put forth the effort to be knowledgeable about the work I perform
• Professional certification is about promoting the highest standards in our industry
• Personal satisfaction
• It shows I take my job seriously and intend to stay on top of the knowledge I need to do the job well
• It shows I have the experience of clinical chart review for appropriate diagnoses and the clarification/query process to physicians
• The credential sets me apart—I have skills and knowledge
• It’s proof that I value this job, want to continue to do it, and want to improve myself; I feel it’s a definite plus and shows that I take pride in what I do.
• It adds much credibility with the physicians in my institution—I think I am perceived as being more professional and more knowledgeable in my role

From the same survey, several managers told us:

• Certified individuals are viewed as more knowledgeable about coding guidelines and best practices. They are more committed to their work, better trained, and have better understanding of the role and what is required to do the job well. And because of recertification requirements, they stay current with changes in the industry.
• Certification holders often serve as team leads, help with new staff orientation, and staff education.
• It communicates a commitment to their craft. Requirements are such that they have to stay current with on-going changes that are occurring. It helps when interacting with their “customers,” as they really are trained and understand what they are doing.
• Identifies that you have attained increased knowledge related to your daily practice.

What will drive you to seek CCDS certification? Whether personal pride, or a suggestion or requirement from your employer, we are here to encourage your efforts and cheer your accomplishment.

Visit the ACDIS website and download the Exam Candidate’s Handbook for more information about certification.

Editor’s note: Penny Richards is the CCDS Coordinator for ACDIS. If you have any questions regarding the CCDS credential or exam process, contact her at prichards@hcpro.com.

A Note from the CCDS Coordinator: What CEUs can I submit for my CCDS recertification?

ACDIS will accept as many CDI-related CEUs from other organizations (such as AHIMA and JATA) as you wish to submit with this exception: For any event that awards more than 10 CEUs, we will accept 10.

For example, if you attend an AHIMA training and it awards (for example)15 CEUS, we will accept 10 for your recertification.

If you attend an AHIMA webinar or similar training that awards you one or two CEUs, we will accept as many of those events as you wish to submit. We’ll accept the entire 30 you need to recertify.

The key is that no single event can award more than 10.

The same applies to CEUs you earn from ANCC, AAPC, CME, and other agencies that provide CDI-related training. We consider CDI-related training to be the exact kinds of training you mentioned in your initial email: CDI, inpatient coding, technology, DRG, reimbursement, plus anatomy and physiology, ICD-10 disease process.

The document on our website explains how we count CEUS from other agencies:

Item 6:
Submit up to 10 CEUs for other single activities that provide CDI training and education, ICD‐10, clinical (disease or diagnosis), coding, documentation improvement activities, or diagnosis/pathophysiology education from other organizations, such as AHIMA, AAPC and ANCC, and CME credits.

Item 7:
Submit CEUs at a rate of 1‐for‐1 for individual training and education activities that are CDI training and education, ICD‐10, clinical (disease or diagnosis), coding, documentation improvement activities, or diagnosis/pathophysiology education from other organizations, such as AHIMA, AAPC and ANCC, and CME credits.

We routinely accept training from companies such as 3M and Precyse as long as it is CDI-related training, to a maximum of 10 for any single training event. Some companies, such as 3M, Panacea, and Reimbursement Review Associates, have purchased ACDIS CEUs for their large programs, and we accept all of these CEUs. You’ll know if you can submit them all because the certificate will clearly indicate that the program awarded a specific number of CCDS CEUs.

Click here to learn more about CCDS certification.

Call for 2017 Conference Poster Presentations Now Open!

2017 Poster Presentation application period open through December 15!

ACDIS is excited to announce that it is accepting applications for poster presenters at its 10th Annual Conference, to be held May 9-12, 2017, at the MGM Grand Hotel in Las Vegas.

This is a great opportunity for hospitals and other CDI professionals to promote their CDI programs and share them with a national audience. Posters may describe an innovative program process or department expansion, a CDI success story, or an obstacle your team overcame. Posters may not promote a product or service.

If you are interested in presenting a poster, click this link to submit your idea: http://app.keysurvey.com/f/1084930/5a39/

The deadline to apply is December 15, 2016.

Here are some key details you need to know:

• We have room for 40 posters.
• The 2017 Conference Committee will review all applications and select those chosen for presentation. All applicants will be notified of the Committee’s decision by the first week in January.
• Presenters will be given a $200 discount off their conference registrations. If the poster is presented by a team the discount will apply to one member.
• Presenters must be able to spend one hour with their poster during a dedicated poster viewing time. Presenters who do not particulate in the session hour will be billed for the $200 discount. The date and time of the presentation session will be announced at a later date.
• We will approve one application per facility (unless space permits additional posters).
• Maximum poster size requirements have CHANGED. Posters may be NO WIDER than 36 inches and NO HIGHER than 48 inches. Posters exceeding these limits will be turned away and the presenter will be billed for the $200 discount.

We look forward to hearing from you with your poster idea!

Thanksgiving mishaps? There’s an ICD-10 code for that!

It’s Thanksgiving! Time to celebrate all the ICD-10 codes you (hopefully) won’t actually encounter this holiday.

As we prepare for the Thanksgiving holiday with family and friends and give thanks for all of our blessings, it is important to be ready with appropriate codes to accurately document any holiday mishaps.

Here’s a short list to help you quickly and efficiently communicate the information required to file a complaint claim:

For incidents with a fresh (live, not saucy) turkey:

• W61.42 Struck by turkey
• W61.43 Pecked by turkey
• W61.49 Other contact with turkey

For general kitchen and meal prep actions:

• Y93.G1 Activity, food prep and cleanup
• Y21.2 Undetermined event involving hot water
• Y93.G3 Activity, cooking and baking

For dealing with obnoxious Uncle Leo who insisted on pushing his way to the dessert table:

• Y04.2 Assault by strike against or bumped into by another person

For your mother-in-law’s criticism of the lumpy gravy (which we know was not lumpy):

• Z63.1 Problems in relationship with in-laws

For activities post-meal to work off effects of R63.2 Polyphagia (overeating):

• W21.01 Struck by football

For Friday morning:

• W72.820 Sleep deprivation

Editor’s note: The ACDIS office will be closed for the Thanksgiving holiday and will reopen on November 28. Please send along your most common documentation improvement opportunities either in the comment section or via email to mvarnavas@acdis.org.

A Note from the CCDS Coordinator: Exam prep tips from our education director

CCDS Exam Study Guide

by Penny Richards

As the coordinator for the Certified Clinical Documentation Specialist (CCDS) exam program, lots of folks ask me for CCDS exam prep tips. But I’m not a CDI professional—I don’t even play one on television—so I asked our CDI Education Director and Boot Camp instructor, Laurie Prescott, RN, MSN, CCDS, CDIP, CRC, for her expert advice.

“Some of getting ready for the exam is mental,” she told me. “If you’ve been working as a clinical documentation specialist for the minimum two years required [to sit for the exam], and you understand the role, you likely have the skills you need to pass.”

Prescott also provided me with a list of great tips that I thought I’d share with you:

1. Use the CCDS Exam Study Guide, which comes with an online practice test.
2. If you are an ACDIS member, take advantage of the great information on the website and the ACDIS Forum to talk to other members about their preparation and exam experiences.
3. Read the 2016 ACDIS/AHIMA Query Practice Brief to help you understand compliant query practices.
4. You must know how to use the DRG Expert. If you are encoder dependent and don’t know how to use the book, you’re going to have a difficult time. Find someone who can show you how to use the book, perhaps a member of your CDI or coding department. It’s not easily self-taught.
5. Read the Official Guidelines for Coding and Reporting and be aware of the importance of the AHA’s Coding Clinic for ICD-10-CM/PCS. I am always amazed by the number of people working in CDI who have never picked up a coding book or read coding guidelines.
6. Understand sequencing rules.
7. A CDI Boot Camp would be helpful if you have the time and resources.
8. Think about how you perform the role of CDI, how you review a record, and prioritize patient care.
9. Metrics and analytics measure department success and some CDI specialists may not be familiar with this aspect of the program. Sit with your manager and ask him or her how to develop and interpret the data. Learn how to define and calculate the case mix index. Know what a query response rate is.
10. Think about areas you may not have a lot of experience in, such as a specific clinical subject, procedures, etc., and study up on this area. Remember, this exam tests the overall function of CDI practice, meaning it may cover information not currently pertinent to your role due to the limitations of your facility.
11. Finally, while it’s important to study and prepare, don’t try to do it all the night before.  Eat a good dinner and get a solid night of sleep.

Thank you, Laurie, for providing these tips! For more information on CCDS certification, click here.

A Note from the CCDS Coordinator: Recertifying your CCDS is easier with new application

by Penny Richards

Is it time to recertify your CCDS certification? You’ll find the process faster and easier now that ACDIS has introduced the new editable PDF application and pay-online features.

Visit the “Recertification” section on the Certification page on the ACDIS website to download the application. Fill it in, save it, and email it to the address shown on the first page. Click the link to pay online. If you prefer to pay by check you can print out the completed application and mail it to us.

• Click here for the application.
• Click here for the recertification requirements.
• Click here for a list of items we accept for CCDS recertification.
• Email your application to ccdsapp@acdis.org.

You may submit your application no earlier than 60 days before your recertification due date. Remember, it’s your responsibility to know your recertification due date. It’s due every two years from the date you passed the exam (look at your certificate or score sheet). We send at least three reminders to the email address we have on file. We are not responsible for emails your facility may block or if you changed emails or jobs.

To recertify, you need to submit evidence of having earned 30 continuing education units (CEUs). All CEUs must have been earned in the time you held the certification or since your last recertification period. Additional CEUs cannot be used for a future recertification. Note the restrictions outlined on the recertification application and on the list of accepted CEUs (link above). Keep copies of your CEU certificates in case your application is selected for an audit.

Editor’s note: Penny Richards is the CCDS Coordinator for ACDIS. Need to know your recertification due date? Contact her at prichards@hcpro.com.

A Note from the CCDS Coordinator: Electronic application process available

by Penny Richards

Those applying to take the CCDS exam or recertify no longer have to write their applications by hand, since ACDIS implemented new editable PDF applications, candidates can complete electronically, on their computer.

The new forms are now available on the ACDIS website for exams, re-exams, and for recertification. Visit the ACDIS site and go to the Certification section. Click on “How to Apply” or “Recertification,” locate the form you need, and click on the link. Or just click the appropriate a link below:

• To apply for the exam
• To apply for a re-exam
• To submit your recertification

Save the form to your desktop using the format indicated at the top of each form, such as CCDS_EXAM_PRICHARDS (use your first initial and last name—the example uses my name).

Fill out the application with your information, save it again, and then email it to ccdsapp@acdis.org.

Do not provide payment information. Instead, click the link on the second page of the application and pay through our secure online store. If you prefer, we will call you for your credit card information. You can indicate in the body of your email that you wish a call. You may also print the completed application and mail it to us with a check.

The new process is really easy and a first step to an online certification and recertification processes.

As always, contact me at prichards@hcpro.com if you have questions.

A Note From the CCDS Coordinator: You can do what Sarah did, it just takes hard work

Sarah LaSource

by Penny Richards

Sarah LaSource didn’t set out to do anything extraordinary on July 8. She took the CCDS certification exam—and lots of folks have done that. But she did what no one else has—walked out with the highest score we’ve ever seen anyone get on the exam, either the old or new version.

Sarah scored 116 out of 120, or 96.6% on the exam. Her secret? “I studied hard!”

She planned to take the exam in late June but some work matters arose that forced her to change her exam plans. She took the extra time to study.

She used several resources as she prepared: The CCDS Exam Study Guide, The Clinical Documentation Improvement Specialist’s Complete Training Guide, and The 2016 CDI Pocket Guide (all from HCPro) and the ACDIS/AHIMA joint brief “Guidelines for Achieving a Complaint Query Practice.”

“I took the practice test (in the CCDS Exam Study Guide) several times,” she said. “The first time was to establish a baseline to find my weaknesses, then I went back over those points exclusively to hone in on my deficiencies.”

Sarah is a clinical documentation specialist at Jackson Madison County General Hospital in Jackson, Tenn., and will celebrate three years in the role in September. Her background is in SICU, case management, and utilization review.

“I got into CDI when my husband transferred to Tennessee to go to grad school,” she told me. “I applied here for an opening in case management, and when I met with the recruiter she told me about the CDI opening. I knew someone at my former employer who was in CDI and who tried to get me into it.”

She is pleased she made the move to CDI.

“This is right up my alley,” Sarah says. “I like to try new things and this is challenging. Definitely the favorite thing I’ve done so far in my nursing career.

“It was a difficult test,” she said. “The biggest challenge was the wording on some of the questions. I went back and changed some answers, something I usually don’t do. I’m glad I did!”

Congratulations Sarah. The hard work paid off in a big way.