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Sunday Reading: Using the DRG Expert

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

Most CDI specialists quickly learn the value of the DRG Expert® in their daily practice. The DRG Expert® typically can be found sitting on a CDI specialist’s desk to assist with “all questions DRG related.”

Although most CDI specialists have access to an encoder, CDI staff need to have a general understanding of how to use the manual and how to employ the logic for assigning a DRG code. An encoder automatically applies rationale to “group” the assigned codes and identify principal and secondary diagnoses and procedural codes to a specific DRG.

The DRG Expert®, published by Optum, is updated annually to reflect any changes mandated by CMS in its inpatient prospective payment system (IPPS) final rule. Optum has varied it’s publication over the years, but the principal structure, format, and use of the manual has remained fairly consistent.

The first section lists the DRGs numerically, from DRG 001, Heart Transplant or Implant of Heart Assist System with MCC, to DRG 999, Ungroupable. This list identifies which major diagnostic category (MDC) the DRG belongs in as well as the page number for the full listing.

For example, DRG 682, Renal Failure with MCC, is listed in MDC 11, Diseases and Disorders of the Kidney and Urinary Tract. When you go to the page listed, it identifies DRG 682, Renal Failure with MCC, and provides information pertaining to the geometric length of stay (GMLOS), the average length of stay (ALOS), and relative weight (RW) of the DRG.

The entry for DRG 682 within the DRG Expert® indicates that DRG 682, Renal Failure with an MCC, has a GMLOS of 4.9 days, an AMLOS of 6.5 days, and a RW of 1.5862. Below this is a list of codes and principal diagnoses that map to this DRG. For example, a principal diagnosis of tumor lysis syndrome, oliguria and anuria, or acute kidney failure with lesion of tubular necrosis will map to DRG 682 if an MCC is also present.

Next on this same page is DRG 683, Renal Failure with CC, and 684, Renal Failure without CC/MCC. The same principal diagnoses listed under DRG 682 apply to these DRGs as well. The presence or absence of CCs and MCCs determines the final DRG assignment.

DRG Expert® also lists DRGs by MDC so you can identify which DRGs fall into what category. For example, DRG 163, Major Chest Procedure with MCC, falls into a surgical DRG within MDC 4, Diseases and Disorders of the Respiratory System. Curious about what procedures would fall into the major chest procedures? Turn to the page listed for DRG 163 for the listing.

Editor’s Note: This excerpt was taken from the Online Materials in The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.

Sunday Reading: CDI role in capturing present on admission conditions

27438_mb320896_cdipocketguide_cover_265x265A present on admission (POA) indicator must be reported for all principal and secondary diagnoses and external cause of injury codes. This is required to identify complications of care.

The POA indicators are:

  • Y (Yes): Present at the time of inpatient admission
  • N (No): Not present at the time of inpatient admission
  • U (Unknown): Documentation is insufficient to determine if condition is present on admission (a query may be necessary)
  • W (Clinically undetermined): Provider is unable to clinically determine whether condition was present on admission or not
  • 1 (Unreported/not used): Exempt from POA reporting

A POA indicator of U (unknown) is equivalent to N (no), and W (clinically undetermined) is equivalent to Y (yes).

POA definition: Present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.

POA documentation. Medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission. The term “provider” means a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis.

CMS has no limitation on the time period during which a provider must identify or document that a condition was present on admission.

Editor’s Note: This excerpt was taken from the 2015 CDI Pocket Guide written by Richard D. Pinson, MD, FACP, CCS, and Cynthia L. Tang, RHIA, CCS. Pre-order the 2016 CDI Pocket Guide today. Click here for more information, or contact customer service at or 800-650-6787.

Sunday Reading: Productivity and other metrics

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

A CDI program’s success may be measured against a wide variety of benchmarks. Any analysis of an individual CDI specialist’s success must also take those variables into consideration. Consider examining the following factors when assessing productivity.

Age of the program: An older program may be asked to tackle more complex reviews, provide more educational outreach, and be involved in more cross-departmental meetings and initiatives, which shifts CDI specialists’ focus away from simple record reviews for CC/MCC capture rates.

Experience level of the CDI professional and overall team: Clearly, managers should not expect a new CDI specialist, to review 20 records per day on their first day. When a new CDI specialist (or specialists) joins a team, overall productivity expectations need to be adjusted. Training a new individual requires job shadowing, auditing, lessons, etc., and the best training requires help from the entire team. Similarly, a team with just one year’s worth of experience may not be as efficient as a team whose components have multiple years of experience. These adjustments in productivity expectations need to be clearly documented and communicated to the team and administration.

Hospital size and program focus: Larger facilities require larger teams—there is, after all, only so much one person can do in a day. However, larger facilities may hone their foci to CC/MCC capture or to patients who are past a set number of length of stay days in order to keep their CDI efforts from getting bogged down. Alternatively, smaller facilities may have the capacity to incorporate more expansive efforts into their record reviews. Program focus matters immensely when determining productivity and other measures of individual CDI success and the success of the program. Programs with clearly defined goals can then benchmark productivity and improvement based on those goals.

Editor’s Note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.

Sunday Reading: ICD-10 Coding for Pressure Ulcers

The CDI Specialist's Guide to ICD-10

The CDI Specialist’s Guide to ICD-10

There are few coding guideline changes regarding pressure ulcers (also known as bed sores) in ICD-10-CM. The biggest change is the use of combination codes that capture both the location of the pressure ulcer, including laterality, and its associated stage. The Official Guidelines for Coding and Reporting allows the coding of the pressure ulcer stage based on non-provider documentation as long as the provider has documented the existence of the pressure ulcer at a particular location.

Nursing staff typically perform a skin assessment at the time of admission. Such documentation may provide evidence of an ulcer POA since physicians typically do not reference a pressure ulcer unless it requires treatment (e.g., stage 3 or 4).

A pressure ulcer is coded only once to its highest stage. A healing pressure always remains classified to its highest stage. Although the appearance of a healing pressure ulcer may evolve from a stage 3 to a stage 2, the pressure ulcer remains a healing stage 3. However, once the pressure ulcer is completely healed, it is no longer reported. A stage 3 or 4 pressure ulcer not POA has been identified by Medicare as a hospital-acquired condition (HAC). When a HAC diagnosis does not have a POA of yes, it cannot be used to add a CC/MCC to the claim.

Because an extensive pressure ulcer can encompass more than one anatomical site, ICD-10-CM has code L89.4-, Pressure ulcer of contiguous site of back, buttock, and hip. The word “and” usually means either/or when used in a code title; however, in this case, the patient must have a wound affecting each of these three anatomical sites to report this code. As with the other ICD-10-CM pressure ulcer codes, these codes are combination codes including the applicable stage of the ulcer.

Guidelines for code assignment in ICD-10-CM include a “code first” note in the tabular list, any associated gangrene (I96), which provides sequencing guidance, and thereby affecting DRG assignment when gangrene is applicable. Figure 5.19 illustrates this.

Editor’s Note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Guide to ICD-10, Second Edition, written by HCPro Boot Camp instructors Jennifer Avery and Cheryl Ericson.

Sunday Reading: Compliance involvement in CDI efforts

The Physician Queries Handbook

The Physician Queries Handbook

CDI programs bear the weight of potentially great benefit or potentially great risk for their organizations, depending on the focus and compliance of their query efforts. It is worth mentioning, however, that CDI programs should include input from their facility compliance officer and legal counsel at various stages of implementation and growth.

Ongoing compliance department involvement can help ensure CDI staff structure queries in a compliant manner. Compliance staff can advise the CDI staff members as to whether templated queries are acceptable, too. Such involvement helps ensure that your CDI program meets the doctrine and spirit of the existing regulations.

Since CMS represents the nation’s largest healthcare payer, many CDI programs get their start in conducting record reviews for Medicare patients and/or top diagnosis target areas. However, the goal of improved documentation and patient care should be consistent across payers and disease type, not just improved healthcare documentation for patients who happen to have government insurance.

In addition, the goal of improved documentation and patient care should not focus only on high-cost services such as acute respiratory failure or any other special circumstance. When there is a lack of consistency in policies and procedures, for example, reviewing Medicare and not private payers, the risk for potential misuse and abuse increases.

Editor’s Note: This excerpt was taken from The Physician Queries Handbook by Marion Kruse, MBA, RN.

Sunday Reading: Clinical Indicators

The CDI Specialist's Handbook

The CDI Specialist’s Handbook

The easiest way to ensure CDI specialists submit appropriate queries is through the use of clinical indicators. Clinical indicators are a written set of guidelines based on the most current medical literature that helps the CDI specialist determine when a clinical picture suggests a particular diagnosis. Although medicine is both an art and a science, a physician’s diagnosis is generally guided by a patient’s presenting symptoms, physical findings, and the results of diagnostic testing. By understanding the clinical information a physician uses to make a diagnosis, CDI staff members can ensure their queries are relevant and timely.

Consistent definition of conditions and treatments documented in the medical record is critical for accurate capture of coded healthcare data. However, what one physician may term a diagnosis another physician may label differently, which can lead to inconsistent outcomes.

When crafting queries related to specific topics, refer to peer-reviewed physician journals such as:

  • Journal of the American Medical Association
  • The New England Journal of Medicine
  • Annals of Internal Medicine

Or specialty journals, such as:

  • Stroke for Neurology
  • Critical Care Medicine for Critical Care
  • Circulation
  • Journal of the American College of Cardiology

Professional organizations develop consensus or scientific statements, of which many contain clinical definitions accepted by most physicians and are published for free distribution on their websites such as:

  • American Society of Infectious Disease
  • American College of Cardiology
  • American College of Chest Physicians
  • National Kidney Foundation
  • Society of Critical Care Medicine
  • American Diabetes Association

Also consider incorporating standard textbooks with well-accepted definitions such as:

  • Harrison’s Principles of Internal Medicine
  • Textbook of Medical Physiology


Editor’s Note: This excerpt comes from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition by Marion Kruse, MBA, RN and Heather Taillo

Sunday Reading: Ancillary staff assessments and documentation

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

Respiratory therapists provide descriptions of a patient’s baseline and current respiratory function and identify home oxygen or respiratory support needs. Their documentation can support coding regarding the number hours of ventilation, where appropriate.

Physical, occupational, or speech therapists’ documentation identifies baseline and current function and deficits related to the patient’s conditions that CDI staff can use to support a query. Look for clues such as:

  • Gait disturbances
  • Hemiparesis
  • Dysphagia
  • Dysphasia as a late effect of an old CVA or related to an acute illness

Speech therapist and swallow studies may provide query opportunity for an aspiration pneumonia. Nutritionists’ documentation provides support for diagnoses such as malnutrition, cachexia, nutritional deficits, and obesity. Pharmacists may offer insight to multi resistant organisms or why a specific medication protocol is initiated.

Note, coders cannot assign codes based on the documentation of these caregivers, but CDI specialists need to ensure consistency within the record between the assessments of such caregivers and the treatment and diagnoses documented by the medical staff.

Editor’s Note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.

Sunday Reading: Injuries in ICD-10  

The CDI Specialist's Guide to ICD-10

The CDI Specialist’s Guide to ICD-10

The Official Guidelines for Coding and Reporting state that “traumatic injury codes (S00-T14.9) are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds.” The tabular list note at the beginning of the Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88) tells coders to “use secondary code(s) from Chapter 20, External Causes of Morbidity, to indicate cause of injury.”

Codes within the T section that include the external cause do not require an additional external cause code. In this group, S codes describe various types of injuries related to a single body region, and T codes describe injuries associated with unspecified body regions as well as poisonings and certain other consequences of external causes. Although CDI specialists have not typically queried for external cause codes (E codes in ICD-9-CM and V00-Y99 codes in ICD-10-CM), these combination codes will require additional documentation from the provider detailing the events surrounding the injury once the new code set implementation takes place.

Regarding the circumstances of the injury, when no intent is indicated, the default is accidental. The Official Guidelines for Coding and Reporting I.C.20.h.1 states that “if the intent (accident, self-harm, assault) of the cause of an injury or other condition is unknown or unspecified, code the intent as accidental intent.” Although the available codes include “events of undetermined intent,” they should be used only if the physician specifically documents that the intent cannot be determined.

In ICD-10-CM, injuries are grouped by body part rather than by category. The organization aligns with how providers document injuries—often a systematic progression from head to toe after the most serious injury is assessed. The focus of treatment can be misleading to those without a clinical background or expertise coding traumatic injuries. For example, a patient may be in the intensive care unit for a neurological injury that requires a high level of nursing care and repeat imaging, but if the coder does not review the nursing notes and imaging reports, all he or she may notice is that an open fracture of a limb was treated with required antibiotics and surgical care.

Although the grouping changed, Official Guidelines for Coding and Reporting are similar, calling for separate codes for each injury unless a combination code is required. Remember that a code can only ever be reported once, so duplicate codes should never appear on a claim. Also, use of a combination code may require a query if the documentation does not already support use of the particular combination code. Figure 5.10 illustrates some of the changes in the injury code set.

Codes organized by type of injury and then by site:


  • Fractures (800–829); e.g., skull, upper limb
  • Dislocations (830–839)
  • Sprains and strains (840–848)
  • Intracranial injury (850–854)
  • Internal injury (860–869)
  • Open wounds (870–897)


Codes organized by site and then by type of injury:


Example: Injuries to head (S00–S09)

  • Superficial
  • Contusions
  • Open wounds
  • Fracture
  • Dislocation, etc.


Editor’s Note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Guide to ICD-10, Second Edition, written by HCPro Boot Camp instructors Jennifer Avery and Cheryl Ericson.

Sunday Reading: Public reporting of quality metrics

The Physician Advisor's Guide to CDI

The Physician Advisor’s Guide to CDI

CMS has its own quality reporting mechanism through which the public may peruse the data to identify which hospital or physician provides the best services for their particular conditions. Medicare’s Hospital Compare website has information about the quality of care at more than 4,000 Medicare-certified hospitals across the country. Patients can use it to find hospitals and compare the quality of their care. Hospital Compare was created through the efforts of CMS in collaboration with organizations representing consumers, hospitals, doctors, employers, accrediting organizations, and other federal agencies.

Physicians aren’t left out, either. Medicare’s Physician Compare website allows patients to find and choose physicians and other healthcare professionals enrolled in the Medicare program, as required by the Affordable Care Act. The information on Physician Compare comes primarily from the Provider, Enrollment, Chain, and Ownership System (commonly called PECOS) and other information sources. The information on Physician Compare is also checked against Medicare claim data.

On Physician Compare, you can find:

  • Addresses where the professional sees patients
  • Primary and secondary specialties
  • Medicare assignment status
  • Whether the individual or group participates in select CMS quality programs
  • Gender
  • Medical school education and residency information
  • Groups that individuals work with (individual profile) or individuals who work with the group (group profile)
  • Hospital affiliation

To the extent that scientifically sound measures are developed and are available, hospitals and physicians are required to include, to the extent practicable, the following types of measures for public reporting:

  • Measures collected under the Physician Quality Reporting System
  • An assessment of patient health outcomes and functional status of patients
  • An assessment of the continuity and coordination of care and care transitions, including episodes of care and risk-adjusted resource use
  • An assessment of efficiency
  • An assessment of patient experience and patient, caregiver, and family engagement
  • An assessment of the safety, effectiveness, and timeliness of care
  • Other information as determined appropriate by the secretary

The idea is that everyone wants to be as good as or better than their neighbors and that everyone wants to do the best job he or she can. Likewise, every patient wants to be treated by the best physician in the best hospital available.

All this represents just the beginning of changes to the way documentation will be used as healthcare reform continues to evolve. The good news is that complete and accurate documentation in alignment with the rules governing code assignment can have a positive effect on almost all of them. The bad news is that government and private payers will be looking for ways to find holes in claims data.

Editor’s Note: This excerpt was taken from The Physician Advisor’s Guide to Clinical Documentation Improvement by Trey La Charité, MD, and James S. Kennedy, MD, CCS, CDIP.

Sunday Reading: Demystifying present on admission indicators

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

Present on admission (POA) indicators are a designation added to a code to better define the timing of a clinical finding. They are associated with most (but not all) conditions, and providers have been required to report POA indicators since October 1, 2007.

To be considered POA, one of the following conditions must be met:

  • The physician included the phrase “present on admission”
  • The condition is included in the patient’s past medical history list
  • The condition was diagnosed during the admission but was chronic in nature
  • The diagnosis was documented on admission as “possible,” “probable,” “rule out,” “suspected,” or “differential on admission” and was subsequently confirmed at discharge
  • The condition developed during an outpatient encounter, such as in the emergency room, physician’s office, outpatient surgery, or observation prior to the inpatient order being written
  • The signs and symptoms of the condition were clearly POA and the documented condition was linked to a presenting symptom

Reporting options include:

  • Y = Condition was present at the time of inpatient admission
  • N = Condition was not present at the time of inpatient admission
  • U = Documentation is insufficient to determine whether condition was POA
  • W = Provider is unable to clinically determine whether condition was POA
  • Unreported/not used (or “1” for electronic billing) = Condition is exempt from POA reporting

If a condition cannot be identified as POA, its corresponding ICD code will likely not meet the criteria for a principal diagnosis and should be scrutinized before being assigned as such. However, the ICD Official Guidelines for Coding and Reporting does allow for a condition that was not clearly identified as being POA in early notations to be accurately classified as POA in later documentation, particularly if the condition required further analysis or study to be correctly recognized. CDI specialists should query for clarification when the status on admission is unclear.

Editor’s Note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.