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Sylvia Hoffman, RN, is a CDIS in Tampa Florida. She has been a nurse for more than 20 years and enjoys writing, painting, and travelling.

Join us in Seattle for the CDI Boot Camp

Boot Camp filming

CDI Education Director Cheryl Ericson, Adjunct Instructor Sylvia Hoffman, Sound Manager Jay Heard and Lead Cameraman Ryan Barret during a previous taping session at ACDIS headquarters.

Please join me in Seattle this coming April for the CDI Boot Camp. So many CDI specialists have stood in your shoes on the edge of a new career, overwhelmed by the possibilities, intimidated by the amount of information there is to learn. You need not worry, we are here to support you, guide you, and provide you with the tools you need to succeed in your CDI role.

A CDI manager recently attended with her two new staff members. At the end of the class, she explained how valuable her team thought the program was, and was particularly pleased to have picked up a number of new tools herself. Another attendee, Virginia Wilson, Clinical Documentation Nurse Brooklyn Hospital Center, Brooklyn, N.Y., told us “The CDI Boot Camp exceeded my expectations, it tied all the loose ends I had questions about regarding DRGs, queries, etc.”

Whether you are brand new to the field or have self-trained working in CDI for a while, the four-day Boot Camp will help open your eyes to all possibilities this profession holds. As an added benefit, we’re offering $150 off the April date of CDI Boot Camp. To receive the discount, please use discount code ET315667.

If you’ve been working as CDI specialist for a few years now but worry about how the implications of ICD-10-CM/PCS on your query efforts consider joining us for the two-day pre-conference ICD-10 for CDI Boot Camp.

I look forward to meeting you at this or another CDI training program in the future.

Sylvia Hoffman, RN, C-CDI, CCDS, CDIP
CDI Boot Camp Instructor, HCPro

ICD-10 for CDI Online Boot Camp filming begins: Lights, Camera, Action

Boot Camp filming

Production Coordinator Jessica Underhill, CDI Education Director Cheryl Ericson, Adjunct Instructor Sylvia Hoffman, Sound Manager Jay Heard, and Lead Cameraman Ryan Barret

This week I headed up to ACDIS headquarters in Danvers, Mass., for the filming of the ICD-10 for CDI Online Boot Camp, with lead instructor Cheryl Ericson. In a few weeks, we will both return to film the updated Clinical Documentation Improvement Online Boot Camp.

This is an exciting time for our profession, and the bar has been set high. This is the most cutting-edge material ever compiled regarding what CDI professionals need to know about ICD-10. The course includes the latest CC and MCC lists, new coding guidelines, and code changes.

To prepare, there is writing, re-writing, editing, and practice the weeks before filming. Camera crews and sound crews are gathered, materials printed, schedules set.  Wardrobe is selected, makeup applied, last minute details ironed out, and finally, it’s show-time! The schedule is challenging, and lights are hot, but everyone is invested in producing the highest quality product.

This is the best year yet and although I know we won’t be up for any Academy Awards, everyone involved certainly deserves a big round of applause!

If you have attended a CDI Boot Camp, either online on in-person, let us know what you liked best about the experience! We love to hear from you!

Words to clarify by

Use these common phrases as clues for further investigation.

Many novice CDI specialists do not readily identify when a diagnosis needs clarification. The following list is intended to serve a gentle reminder to “dig deeper.” Here is a list of “clue” words to help you identify when a query may be needed for clarification or specificity.

AMS needs clarification as to possible Acute Confusional State, Alzheimer’s Dementia, or Alzheimer’s with Behavioral Disturbance. If with associated Infection, metabolic condition, etc. it could also indicate Encephalopathy.

Urosepsis could be UTI or Sepsis secondary to UTI.

Hypoxemia/Respiratory Insufficiency could indicate a diagnosis of Acute Respiratory Failure or Acute post Operative Respiratory Insufficiency if the indicators are present. (E.g. Use of C-pap or Non re-breather mask, or O2 saturation less than 92%).

Anemia requires specificity of Chronic Anemia, Acute Blood Loss Anemia, Aplastic Anemia, etc.

Renal insufficiency/chronic kidney disease (CKD) requires added specificity for the stage of the CKD, the Creatinine baseline and further specificity as to possible Acute Renal Failure (ARF), and if indicators present (E.g. nephrotoxic medication usage) ARF with Tubular Necrosis.

FTT, Anorexia may indicate Malnutrition. If present, further specify as to whether it is mild, moderate, or severe.

CHF requires specificity of acute or chronic and systolic or diastolic heart failure.

Right/left sided weakness may indicate a diagnosis of hemiplegia or hemiparesis.

Problems with speech post CVA may indicate a diagnosis of Aphasia.

Drug use History requires clarification of use or abuse and if the Drug Use/Abuse is Ongoing.

Abdominal pain requires documentation of an underlying diagnosis. (E.g. Ulcer, Acute Pancreatitis, etc)

Chest pain requires documentation of an underlying diagnosis. (E.g. CAD, Angina, Costochondritis, etc.)

Gangrene-requires further specificity as to “Wet” infectious or “Dry” ischemic Gangrene

Poorly controlled Diabetes needs clarification whether Uncontrolled or Controlled Diabetes Mellitus.

Hypertensive Emergency needs clarification as to Malignant or Accelerated Hypertension.

DVT needs clarification as to Deep Vein Thrombosis or Thrombophelbitis.

I&D needs clarification as to whether this means Irrigation and Drainage, Exisional Debridement or Non Exisional debridement. (If exisional debridement performed then documentation must state if scalpel was used, clear margins obtained, and depth up to and including deepest layer.)

↓↑Na is not a diagnosis. Documentation must be obtained as to possible Hyper/ Hyponatremia.

Crafting CDI goals for 2012

Set goals and when you've accomplished them be sure to give a toot on your horn.

This is the time of year for CDI specialists to evaluate their programs and set goals for the coming year. What are your goals?

Beware of setting unrealistic or lofty expectations. Everyone would like to make three million dollars, and raise their facility’s case-mix index by two points but are you setting yourself up for failure. Perhaps you can start with capturing better specificity for patients admitted with CHF.

Set your own personal goals, such as becoming more active in your local ACDIS group, or requesting to attend the National ACDIS Conference. You may want to get your CCDS certification, or write an article for the ACDIS Blog. Your goals can be as simple as creating a poster for the doctors’ dictation area.

Write your goals down and then periodically look at the list and strive to attain the items listed. This list may also be used later for your yearly evaluation, to serve as a reminder to others of your achievements. It doesn’t hurt to toot your own horn periodically.

Set program goals as well. This may constitute a review of policies and procedures or the formulation of a Recovery Audit Contractor pre- audit group. And, it is not too early to start getting ready for ICD-10. (Actually, you should already be getting ready, but that is a different topic.)

Take a few minutes at the end of the day and jot down a few ideas. These seeds for thought may take full bloom come the springtime.

So with this in mind, have a wonderful holiday and a fantastic new year!!

Santa’s not the only one watching to see if you’ve been bad or good

Singing: He sees you when you’re sleeping. He knows when you’re awake. He knows if you’ve been bad or

What will the jolly old elf will bring to the RAC offices?

good, so be good for goodness sake.

Remind you of anyone? No? Here’s a hint. It rhymes with knick-knack but these groups aren’t known to be particularly “nice.”

Audit contractors (Recovery Audit Contractors or RACs) are not Santa, but they are watching you, and they certainly know if you’ve been naughty.

Let’s be realistic, all of your facility healthcare data is being scrutinized, analyzed, and compared. Statistical data gives audit contractors an idea of which hospitals fall off the bell curve, and what diagnosis qualify as low hanging fruit.

If your hospital has a 30% sepsis admission rate and all other hospitals in your area have a 10% rate, then you pretty much are going to stand out like a sore thumb. Do not fool yourselves. It is not because your CDI department is that much better at capturing sepsis as a diagnosis.

Take a look at how your facility does business and whether it may be pushing the envelope when it comes to leading queries and creative coding. Does your hospital follow AHIMA’s recommendations when it comes to formulating compliant queries?  The brief clearly states that:

“Individuals who perform the query function should be familiar with the AHIMA Standards of Ethical Coding, which direct coders to assign and report only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines.”

Next, review and update your own internal policies and procedures. Many hospitals create these policies and then never check to make sure the rules are being followed. The AHIMA guidance states:

“Individuals performing the query function should follow their healthcare entity’s internal policies related to documentation, querying, coding, and compliance, keeping in mind that data accuracy and integrity are fundamental HIM values. Only diagnosis codes that are clearly and consistently supported by provider documentation should be assigned and reported. A query should be initiated when there is conflicting, incomplete, or ambiguous documentation in the health record or additional information is needed for correct assignment of the POA indicator.”

Lastly, create an audit process to ensure that both your own policies and AHIMA recommendations are being followed. Healthcare entities should consider establishing an auditing and monitoring program as a means to improve their query processes. They can consider several methods for this ongoing process. Queries can be reviewed retrospectively to ensure that they are completed according to documented policies. This might include reviewing determining whether the:

  • query was necessary
  • language used in the query was not leading or otherwise inappropriate
  • query introduced new information not otherwise included in the medical record

Based on the results of this review, the healthcare entity may need to identify specific corrective actions. For example, any cases identified as containing inappropriate queries which resulted in inaccurate code assignment will require corrective action and possibly rebilling. Inappropriate queries should be tracked, trends identified, and appropriate education, training, and/or disciplinary action taken when warranted.

No one wants to get a lump of coal in their stocking. And no one wants to give the RAC or other auditor a Christmas bonus. Take time this holiday season to make some New Year resolutions and ensure that your facility is compliant and knowledgeable. You will then reap the rewards of a stocking filled with peace of mind.

Books a CDI specialist shouldn’t be without

I had the pleasure recently of working with a fantastic group of medical coders. We shared many great stories and laughed about our

Need help picking the right CDI reference book?

various adventures in the field of documentation integrity. And then we started to talk about reference books we can’t live without. Yes, my inner nerd does periodically come out to play, and I found myself becoming envious. It seemed like coders had better books.

When I first started work as a CDI professional, I was given a notebook, a CC/MCC pocket reference guide, and a card with normal lab values. As I became more knowledgeable and realized how much I didn’t know, I started to print out copies of Coding Clinics and starting reading and re-reading the Official Guidelines for Coding and Reporting. That was the total extent of my reference materials.

Eventually, I found my DRG Expert. I love my DRG Expert and I don’t go anywhere without it. The coders were amazed by how quickly I could look up DRG’s without using an encoder. I felt like a Chinese mathematician using an abacus to solve difficult equations. That capability didn’t come easy, however. It took years of work. And like anyone else, I still use an encoder on occasion.

A CDI specialist (especially a reference geek like me) cannot live on Coding Clinic, Official Guidelines, and The DRG Expert alone. You can’t be expected to know everything, that is why it is important to have a resource where you can easily find the information you need. I encourage CDI nurses to obtain those resources needed to assist them in their daily work. Hospitals may not be willing to pay for resource materials (shame on them) so, consider buying one copy for the department to share, or invest in one book a year.

Sylvia and Glenn sign copies of the CDI Specialists' Guide to ICD-10 during the 2011 ACDIS Conference.

Since those early days, I have found a new wealth of helpful references through ACDIS. The Clinical Documentation Improvement Specialists Handbook, Second Edition by Marion Kruse and Heather Taillon is fantastic as is The Physician Queries Handbook, by Margi Brown, James Kennedy, Marion Kruse, and Lynne Spryszak. (I’ll also mention the newly released Clinical Documentation Improvement Specialsit’s Guide to ICD-10 that I worked on with Glenn Krauss, not to toot my own horn but because CDI specialists need to start learning about ICD-10 as soon as possible. Well, that and ACDIS Assistant Director/Book Editor Melissa Varnavas would kill me if I didn’t mention it!)

Resources and reference materials need not come only from books. Don’t forget about all the great resources in the ACDIS Forms & Tools Library, too. At any rate, if you are in doubt on what books to buy don’t worry, just ask a coder or fellow ACDIS member to recommend a good one!

A query poem to wake up your program

It is National Poetry Month, after all.

Query in the morning
Query after lunch
Query in the evening
‘Cause I have a strong hunch

Query for anemia
Query for a link
Query for a coma
It makes the doctor think

Query for the failure
Query for the cause
Query for pneumonia
There is no time to pause

Query for exacerbation
Query for TIA
Query for specific words
‘Cause they don’t know what to say

Query on computer
Query with a pen
Query all the more
When we change to ICD-10!

Watch for substance abuse, emotional distress in documentation around the holidays

The Thanksgiving holidays are often filled with excesses. There is the obvious food and drink extravaganza; the all day football watching; the exhausting shopping on black Friday; the unsolicited parental advice, the crying children and of course the many pounds gained.

The holidays also account for a greater incidence of depression, stress, substance abuse and suicide. The numbers of people choosing to take their own lives is increasing. By some estimates a person tries to take their life every 39 seconds. Suicide is not limited to a single age group, racial group, or socioeconomic class. Currently, among the 15- to 19-year olds, suicide is the second leading cause of death (following accidents). The suicide rate has tripled over the last 30 years in this age group. The elderly (often following the death of their spouse, or favorite pet) are another large group very much at risk. (Kirsti A. Dyer, MD)

There are conflicting reports as to whether the suicide rate increases during the holiday, or afterwards. Whether or not there is an increased incidence of suicide, we know there is an increased incidence of depression, mental health visits and the blues, both during the holiday and up to three weeks after the holidays.

Clinical documentation specialists need to be aware of the specialized documentation needs when dealing with substance abuse and the rules that govern the admission of a patient with an overdose.

Physicians historically document “history of drug use” when a patient is admitted, regardless of whether the patient has a current positive drug screen. The physician must be educated on the benefit of documenting drug use/abuse ongoing. The capture of this diagnosis is a comorbidity and therefore, reflects the extra resource consumption and increased severity of illness that these patients possess.

Drug overdoses or the admission for affects of drugs taken with alcohol, are coded to DRG 917-918-Poisoning and toxic affect of drugs.

Similar comorbidities include ETOH withdrawl delirium, ETOH or drug withdrawl, ETOH induced persisting dementia, ETOH induced psychotic disorder with hallucinations, and ETOH mania, psychosis, or mood disorder.

May your holidays be blessed and may you have a wonderful Thanksgiving holiday .

Don’t be haunted by ‘failure to thrive’ documentation zombies

"Failure to thrive" might be one way to describe the zombie nation.

Halloween is almost upon us and it is during these spooky times that many a CDI specialist is most at risk of witnessing one of the most horrific sights in the hospital setting. It is the documentation of failure to thrive (FTT) and altered mental status (AMS). The documentation of these two diagnoses can cause many a seasoned professional to shriek and shake.

Queries are left and sometimes replied to, but many physicians view these forms as pesky little goblins and not the beautiful gems that they truly are. Clinical documentation specialists are good witches not bad ones. (Think wizard of OZ)

Try as we might, it is difficult to retrain many physicians to alter their old documentation habits. They have been writing this way for so long that they are not cognizant of the possible harm this may cause.

Does this patient with AMS actually have an state of acute confusion state or are they a patient with Alzheimer’s  related dementia with behavioral disturbance or is the patient suffering a drug induced delirium or is it a case of encephalopathy?

Similarly, the physician needs to determine if the patient with FTT actually have cachexia, intestinal malabsorption, or malnutrition.

There is no trick.  All that is needed is a definitive diagnosis, not a symptom. But there is a potential treat waiting those who appropriately document more specific diagnosis. Such documentation can positively affect the physicians’ risk of mortality and severity of illness ratings. It can increase a estimated patient’s length of stay, and  comorbid or major comorbid conditions and they may better reflect the E&M billing level for severity.

Florida CDI meeting participatants were ‘off to the races’

The Florida ACDIS meeting held at Regional Medical Center in Bayonet Point on April 30th was a hit!! Everyone enjoyed themselves and the Derby Day theme was fantastic.

Florida ACDIS members decked out in their finest for their Derby Day meeting.

The beauty was in the details: The roses at each place setting, the derby day cake, the decorations, and the derby trivia contest were only a few of the highlights. Everyone modeled their hat on the red carpet and George Hachey from Shands in Gainesville stole the show with his catwalk moves.

The three quest speakers were phenomenal! We were very fortunate to have Margi Brown, Dr. Betty Bibbins from Docu- Ed, and Bert Amison from KPMG. All three gave fantastic power point presentations. Dr. Bibbins even donated an antique derby pin to use for our raffle.

The annual survey results were given out. It is no surprise that many hospitals are feeling a financial pinch from the current economic climate.  It is for this reason that the regional meeting is so important.  There is no cost to members, there are no transportation or hotel expenses, and there are CEU’s awarded. The next meeting will be held on a Saturday, since it appears to be difficult for some members to take time off during the week.

There was much interest in the Certified Clinical Documentation Specialists (CCDS) credential and exam, and some excitement about the recently published study book. Luckily, a copy arrived at my house a day before the meeting so everyone was able to sneak a peak at it during breaks.

Special thanks go out to Charlie Morrell, RN, who did a lions share of the work, from making the wooden horses, (complete with little jockey hats), to securing financial support (KPMG generously supplied the food and refreshments for the event.)