All Entries in the "CDI Profession" Category

Conference Q&A: ‘CDI Career Ladder’

Want to climb the CDI career ladder? Two ACDIS speakers will tell explain how during today's presentations.

Editor’s Note: This post is part of an ongoing series of Q&As with presenters and participants from the 2012 ACDIS Conference in San Diego. The following features Jennifer Love, RN, BA, CCDS, and her  co-presenter Janet Gentle, RN, BSN, MSN, CCDS on the presentation “CDI Career Ladder: Two Perspectives,” which takes place today, Thursday, May 10, 3:15-4:15 p.m.

Q: How long have you been a CDI professional? 

JL: In 2008 I was hired as the manager of CDI for Novant Health.  In 2011, I became the area director of Clinical Documentation Improvement for Kindred Healthcare.

JG: Seven years.

 Q: What inspired you to follow this career path? 

JL: When I was a Surgical Care Improvement Project analyst at Novant, my senior director informed me that the hospital system was considering implementing a CDI program.  In discussions that followed, I was allowed to purchase The Clinical Documentation Improvement Specialist’s Handbook.  I read that book cover-to-cover! I was hooked!  CDI was something fresh; a new challenge which definitely sparked my interest.  I was hired as the manager of Clinical Documentation Improvement and the CDI program was implemented shortly thereafter.

JG: We had consultants who were brought in to redesign our case management (CM) department and establish a CDI program. They encouraged me to interview for the dual CM supervisor/CDI position which, within three years, turned into a full-time CDI position.

Q:  What should someone who is interested in becoming a CDI specialist do to begin their career? 

JL:  I’d recommend they read The Clinical Documentation Improvement Specialist’s Handbook, too, or check out the ACDIS website before making the leap.  I would also encourage them to get approval to shadow current CDI specialists.

To take the CDI career path, the individual should be very attentive to detail, e computer savvy, and possess clinical expertise. To take on this career, the individual will be required to communicate effectively to everyone from coders to physicians.  I’d also tell them to be honest with themselves regarding their weakness and strengths.  If the CDI role plays up your strengths—go for it!  I wish you the best of luck!  Give yourself time to master this role, however.  It will take months before you will feel truly competent.  One more thing, you will make mistakes.  No one in this field is perfect.

JG: Definitely research the CDI role first. And take part in ACDIS/AHIMA educational opportunities. In fact, join ACDIS/AHIMA on either the national or local level for educational and networking opportunities. Attend conferences/educational programs such as Boot Camps and look for an entry level position with a facility that will help train you.

Of course someone looking to advance their CDI career should be able to research best practices to improve current processes, know how to monitor effectiveness via internal audit/productivity measures, understand the importance of developing policies and procedures. There are other ways to advance your career, too. Those on the cutting edge of this profession know how to develop ICD-10 compliant queries or have become involved in their local ACDIS chapter.

Additional opportunities exist down some unexpected avenues such as CDI travel assignments and remote CDI at home, etc.

Q:  If a CDI professional has been working in the field for a few years what steps should they take to advance their role, program, and/or career? 

JL: Don’t let yourself stagnate.  Always be reading something or pursuing something for your professional growth.  Don’t rely solely on your employer to sign you up for conferences, classes, etc.  Take the initiative yourself and your employer will take notice. Also, if you are interested in an opportunity for advancement—speak up! Your boss can’t read your mind. Once you’ve shared your interest, your boss then starts ‘grooming you’ for the next big thing. You never know!

JG:  Develop a CDI team leader/coordinator position and consider yearly salary market adjustments in addition to raises. Look for reimbursement for conference attendance and tie that attendance to team education and CDI program process improvements. There are increasingly opportunities in collaborative environment and autonomous practice

Q: What steps can a CDI manager take to help staff members feel there are opportunities for advancement at their own facility? 

JL: One thought is to implement a CDI career ladder program.  Another thought is to encourage the employees to build relationships with quality, HIM, case management, and other related departments within the facility as opportunities for advancement may exist and/or open up in one of them.  The specialized experience of a CDI professional along with the other skills one possesses would make for an appropriate transition during a needed time of new projects, etc.

 JG: As mentioned earlier managers need to provide different educational opportunities and tie those opportunities to overall process improvements within the program. Empowering staff to take ownership of their own career is also important.

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

JL: I look forward to seeing the beautiful city of San Diego, those familiar smiling faces, and taking away at least one pearl of wisdom that will take me to the next level of CDI expertise.

JG:  Presenting about career ladders! I am also looking forward to all the networking opportunities the great educational opportunities. Our local chapter the Michigan ACDIS is having dinner together on Wednesday night and then Friday I’m looking forward to the great Local Chapter Networking Lunch and Event. Of course, I’m looking forward to the sunshine and visiting the Pacific Ocean.

Q: What inspired you to become an ACDIS conference speaker? 

JL: I felt compelled to share valuable insight from my recent CDI career change with my ACDIS colleagues.  I wanted others who may be considering a CDI job change to be even more equipped and informed than I was during my job search.

JG: I am very passionate about creating a career ladder for nurses in alternative practices, such as CDI.  Historically, clinical ladders have been developed for bedside nurses.  The development of the specialty ladder at Northern Michigan Regional Hospital was innovative and based on original literature search, and it has afforded all NMRH nurses equity and opportunity for professional advancement.

May 6-12 is National Nurses Week! Let’s celebrate

The American Nurses Association (ANA) and nurses across the country are celebrating National Nurses Week, May 6

Florence Nightingale says Happy National Nurses Week!

-12. According to the ANA web site, National Nurses Week is celebrated annually from May 6, also known as National Nurses Day, through May 12, the birthday of Florence Nightingale, the founder of modern nursing.

ACDIS would like to pause for a moment and join the many voices that cheer in the nursing profession and the role such professionals fill. We support your tireless efforts, thank you for your skill and insight, and are blessed by your compassion and kindness.

Our ACDIS membership is approximately 75-80% RNs that have since moved into CDI, but it’s certainly true that once a nurse, always a nurse.

May the next year bring you personal and professional success and satisfaction!

The clock strikes twelve…

Now that you have the extra time...

…and the documentation coach will turn into a pumpkin if you’re not on time. As a CDI specialist, what has been your approach to ICD-10? Are you hoping it will go away? Are you waiting for 2014? Are you preparing now?

Although the official start date for ICD-10 CM and ICD-10 PCS is expected to move out to October 1, 2014, the start of fiscal year 2015, most hospitals should be, and are, preparing now.

AHIMA has produced an ICD-10 checklist, with a detailed timeline and suggestions as to who should be involved at what stage of the process. CDI specialists aren’t specifically mentioned until the very end, as one group of the many users who will need ICD-10 education, but their role will be critical.

According to the timeline, you should have already looked at your physicians’ documentation to see if it will stand up to ICD-10 coding requirements, and should be developing and implementing strategies to address any weaknesses in that documentation. You can’t do that if you don’t know ICD-10. If you are not expert in anatomy and physiology (A&P), get refresher training now. While you are likely not coding the chart, you are ensuring that the documentation is sufficiently detailed to meet ICD-10 (especially PCS) coding requirements, and that means having expert understanding of A&P.

If your hospital hasn’t decided what changes to it needs to make in its electronic documentation processes, get involved. (See related articles CDI input helps EHR implementation succeed and E-nvolved: The case for planning EHR implementation available in the CDI Journal archives.) You are the experts on documentation requirements. It will be much easier to work the documentation requirements into your electronic system before implementation than to try to retrofit a process into an existing system later.

You may think it is too early to learn about ICD-10, or that if you learn it now, you will forget it by the implementation date because you are still using ICD-9.  Think back to when you first learned the MS-DRG system and ICD-9-CM codes. How long did that take?  Aren’t you still learning? Don’t you have to give yourself time to become competent so that you could educate your doctors?

Consider this: Everything you teach physicians about documentation for ICD-10 will improve their documentation under ICD-9. Your coders are not going to complain that you enabled the physician to be too accurate. When you send a query, physicians generally doesn’t know or care about the coding rule or the classification system that triggered the query. They just know they have to answer to the level of detail you’re asking, so start sending questions that generate ICD-10 compliant answers. When you learn ICD-10, you can start guiding your physicians in the right direction, and the official transition in 2014 will be much less painful.

I liken the preparation for ICD-10 to that, a little more than a decade ago, for Y2K.  Some people feared disasters including nuclear holocaust, and when nothing happened on 1/1/2000, they were almost disappointed. In reality, the preparation had been impressively thorough and left nothing to chance. Although the world might not end if we aren’t ready for ICD-10, getting all the details covered before the official implementation date can make the actual conversion more like distant thunder clap than an Armageddon explosion.

Training seminars, boot camps, and books abound. Take advantage of everything that’s offered, and ask for training if you haven’t received any. If you’re just starting to train, review CMS’s overview of ICD-10. The World Health Organization offers an ICD-10-CM online training tool that’s free and easy to use.

As a CDI consultant, I knew that at some point I would be required to provide ICD-10 documentation education to new CDI specialists. So I decided to pull out the ICD-10-CM official guidelines and actually compare them side by side with the ICD-9 CM guidelines. Not only did I learn about ICD-10-CM, but I refreshed my knowledge of ICD-9-CM.

Then I began putting together a presentation on ICD-10-PCS, and by working my way through the definitions and the rules, I educated myself. By the time I finished creating my PowerPoint, not only did I have a greater understanding of the complexity of the documentation requirements, but I was able to code a simple procedure. I was very proud of myself, too! Now, I didn’t become an ICD-10 expert that day, but by challenging myself to work with it, I found it much less frightening and much less mystifying.

Please don’t wait for education to come to you.  Please don’t wait for someone else to tell you what your CDI process should be. Put the “special” in CDI specialist.

Examine guidelines for medical necessity documentation needs

Because most CMS local and national coverage determinations governing medical necessity and limitations of coverage

Looking for ways to improve your CDI program consider examining records for medical necessity.

center around outpatient procedures (e.g., lesion removals, cataract surgeries, and blepharoplasty repairs), typically physicians’ clinical judgment and medical decision-making alone have qualified as sufficient support for the need for inpatient procedures.

To meet medical necessity for commonly performed inpatient procedures (e.g., hip and knee replacements and spinal fusions), medical necessity for performing the procedure in and of itself is predicated upon supporting documentation in the physician’s office notes. Unfortunately, oftentimes this documentation is sparse, clinically nonspecific, and without sufficient detail to meet the stringent medical necessity requirements by Medicare and other third-party payers. The end result is medical necessity denials for these inpatient procedures for both the hospital and the surgeon. This makes for a tangled web from all aspects of the collection of health information.

Examine guidelines for reporting diagnoses and procedures

The Medicare Program Integrity Manual, chapter six, section 6.5.2, “Medical Review of Acute Inpatient Prospective Payment System (IPPS) Hospital,” and section 6.5.4, “Review of Procedures Affecting the DRG,” contains language on diagnosis and procedure code assignment:

“The contractor shall determine whether the performance of any procedure that affects, or has the potential to affect, the DRG was reasonable and medically necessary. If the admission and the procedure were medically necessary, but the procedure could have been performed on an outpatient basis if the beneficiary had not already been in the hospital, do not deny the procedure or the admission. “

Section 6.5.4 offers guidelines for the MAC when a procedure wasn’t medically necessary:

• “If the admission was for the sole purpose of the performance of the non-covered procedure, and the beneficiary never developed the need for a covered level of service, deny the admission;
• If the admission was appropriate, and not for the sole purpose of performing the procedure, deny the procedure (i.e., remove from the DRG calculation), but approve the admission.

In other words, if the clinical documentation does not clearly and unequivocally support the medical necessity for a procedure, the Medicare contractor will deny the entire stay for both the hospital and the physician. This congruent Part A and Part B denial for medical necessity is becoming more common from a MAC standpoint, as the following information published by MAC Trailblazer Health illustrates:

“Prepay service-specific edits are in place to review services billed with the following DRGs:

• 243, Permanent cardiac pacemaker implant with complications
• 246, Percutaneous cardiovascular procedure with drug-eluting stent with major complications or 4+ vessels/stents
• 247, Percutaneous cardiovascular procedure with drug-eluting stent without major complications
• 460, Spinal fusion except cervical without major complications
• 470, Major joint replacement or reattachment of lower extremity without major complication”

“To increase consistency in Medicare reimbursement, effective November 1, 2011, TrailBlazer began cross-claim review of these services. The related Part B services (i.e., procedure and evaluation and management services) reported to Medicare will be evaluated for reimbursement on a postpayment basis. Overpayments will be requested for services related to the inpatient stay that are found to be paid in error.”

Trailblazer outlines documentation requirements for DRG 470

Trailblazer Health has outlined and defined specific joint replacement (DRG 470) documentation for both hospitals and physicians to follow in support of medical necessity.

Clinical documentation from both the physician’s office as well as the hospital must support medical necessity for joint replacement procedures. Coders cannot directly control the quality and completeness of documentation in the record, but they can certainly familiarize themselves with the guidelines of clinical documentation necessary for joint replacements and apply this knowledge when reviewing these records.

Coders can collaborate with case managers and utilization review staff to identify documentation deficiencies, which place both the hospital and the physician at financial risk for recoupment due to a lack of medical necessity. To this end, consider developing a training program for physicians and other clinical staff that covers principles of documentation to establish medical necessity.

For example, physicians need to be aware that for a knee replacement, they need to document:

• Pain in the knee (e.g., level of pain and whether it has worsened)
• Pain increasing with activity (e.g., whether the pain increases with weight-bearing and daily activities)
• Passive or limited range of motion or swelling of the joints
• X-rays that support any of these findings:
• Subchondral cysts
• Subchondral sclerosis
• Periarticular osteophytes
• Joint subluxation
• Joint space narrowing
• The use of medication that was unsuccessful in providing pain relief

This is quite a bit of information that the physician needs to document to support medical necessity, but without the proper diligence of various parties (e.g., utilization review, physicians, and coders), and without this supporting detail, it could lead to costly denials.

Editor’s Note: This article was originally published on JustCoding.com.

CDI ‘Roadmap’ committee charts program priorities

Don't get lost on the road to success. The CDI Roadmap Committee will offer direction for new programs.

Although you might not have heard of it before, ACDIS has formed a group called the CDI Roadmap Committee to help develop and define some of the core structures that the CDI profession has been lacking. These include the broad goals and objectives of CDI, staffing and productivity considerations, setting new goals for mature programs, and a realistic structured outline to help map out the way.

The CDI Roadmap Committee has been meeting since September 2011. The committee currently consists of the following members:

• Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, ACDIS Advisory Board Member, Independent Revenue Cycle Consultant in Madison, WI.
• Lynne Spryszak, RN, CCDS, CPC-A, ACDIS Advisory Board Member and independent HIM consultant in Roselle, IL.
• Donna D. Wilson, RHIA, CCS, CCDS, ACDIS Advisory Board Member and Senior Director of Compliance Concepts, Inc. in Wexford, PA.
• Cheryl Ericson, MS, RN, ACDIS Advisory Board Member and CDI manager for Medical University of South in Charleston, SC.
• Gail B. Marini, RN, MM, CCS, LNC, ACDIS Advisory Board Member and CDI manager for South Shore Hospital in Weymouth, MA.
• Beth Kennedy, RN, BS, CCS, CCDS, Associate Director, Documentation Improvement Program CMO, The Care Management Company, LLC., Montefiore Medical Center in Bronx, NY.

The majority of the group’s first meeting was spent discussing the purpose and intent of the group and defining both short and long-term objectives. The committee determined that its objective is to create a phased approach to CDI success. The team decided to develop a pre-implementation timeline/checklist, then took a deeper delve into the goals/objectives of a basic CDI program and requirements and expectations for staff.

At subsequent meetings members offered drafts of a pre- implementation checklist with items such as assembling a steering committee and an outline for developing a project plan. The group also discussed sample orientation checklists, collected job descriptions for physician advisors, CDI supervisors, and CDI specialists, and discussed potential CDI evaluation criteria and assessment of CDI staff coding and clinical skills.

The CDI Roadmap Committee will likely break after it completes the “pre-implementation” and “implementation” phases of the timeline, and continue work on “ongoing maintenance” and “advanced level CDI” phases at a later date.

The committee plans to send its work to the ACDIS advisory board for approval and compile its findings in a series of White Papers available as free resources to the ACDIS membership.

Editor’s Note: This article first appeared in the March 15 edition of CDI Strategies.

Everything I need to know I learned from my cat

My cat Thomas as a kitten. Isn't he adorable?

Nobody reads blog bios. But if you read mine, you’ll see mention of Thomas, one of my four cats. I keep his picture as my work computer’s background, and because I have dual screens, I get to look at him twice.

Thomas and I have a lot in common: We’re old. We’re gray. At least one of us doesn’t look a day over 45.  And we know what we like. There are a few things we don’t have in common: He doesn’t like the New York Giants nearly as much as I do, and I don’t lick empty plastic bags very often. (Why do cats do that?)  But I adore him completely, because he brings me joy. So I thought I’d try to discover if any of Tommy’s endearing characteristics could be adapted to my role as a CDI specialist.

• Always inquisitive. It seems like cats never take things at face value. They always have to investigate things for themselves. They are always pouncing off to figure out what made some small sound, pushing their noses into some half opened cupboard door. As a CDI specialist, you have to have this same type of inquisitive nature to look into all the detailed information and push to gain access to other documentation such as nurses’ or dieticians’ notes to help you understand the complete clinical picture.
• Purring when he’s happy. Although I speak pretty fluent cat, and rarely am in doubt as to whether Tom and his fellow cats are due for lunch, most of the time I still have to rely rather heavily on Tom’s nonverbal signals. Cats purr and put their tails straight up when they’re happy; they present themselves in a vulnerable position when they’re open to affection. An interesting phenomenon, though, is that cats also purr when they are heavily stressed. If you don’t evaluate the situation, you won’t interpret their mood correctly. Learn to read your physicians’ signals. Smiling and nodding could be positive signals, or they could be polite ways of trying to get rid of you. Always consider the context of your interactions.
• Marking his favorite human. Yes, that would be me. Cats nuzzle their humans not just for the physical contact, but also to mark the human as their personal (cat-onal?) property using their scent glands. The marking is irrelevant to me, but the contact is precious. And when Tommy rubs his head against me and tells me I’m his favorite human, of course I want to return the attention. Your physicians probably don’t spend much time thinking about you, so when you make contact with them, make it memorable. Let them know they are genuinely appreciated, not only for their documentation skills, but for being great doctors, and even great human beings (when applicable). You might reap some unexpected benefits.
• Being a cat means never having to say you’re sorry. Well, okay, of course if we screw up, we should apologize. But cats don’t feel guilt, at least as far as I can tell. If you yell at them for scratching your sofa, they might skulk for about three seconds, but then they move on. If you keep yelling at them, they’re only going to avoid you, because they’ve already forgotten about the incident and don’t understand why you’re acting out. So when you make a CDI mistake, deal with it and move on. Many nurses have been conditioned to strive for perfection and are used to being chastised when they (of course) fail to be perfect. The word “perfect”  in my opinion has no place in healthcare.  Setting standards is good; setting unrealistic standards is a recipe for failure.

My work environment would be just about ideal if I could review charts with Thomas sitting on my lap. He’s just so darned cute, and he’s also a great typist.

Meet the 2012 CDI Professional of the Year and the winners of 2012 Recognition of CDI Professional Achievement

ACDIS is pleased to introduce the 2012 CDI Professional of the Year, and the two members who will receive the 2012 Recognition of CDI Professional Achievement awards, selected by the 2012 ACDIS Conference Committee. All three will be presented with their awards at the ACDIS conference in San Diego on May 10.

2012 CDI Professional of the Year

Cathy Seluke, RN, BSN, ACM, CCDS, Supervisor Clinical Documentation Compliance

MaineGeneral Medical Center, Waterville, ME

2012 Recognition of CDI Professional Achievement

Dee Schad, RN, BSN, CCDS, Director of the Care Coordination and CDI

Clark Memorial Hospital, Jeffersonville, IN

and

Robert S. Hodges, BSN, MSN, RN, CCDS, Clinical Documentation Improvement Specialist

Aleda E. Lutz VA Medical Center, Saginaw, MI

Meet Cathy

Cathy Seluke received multiple nominations from her coworkers that included these comments:

Cathy Seluke

• “So much of the success of the CDI program at MaineGeneral Hospital stems from Cathy’s operational and clinical leadership through the years.”
• “Cathy displays the qualities of authentic leadership. In addition to her administrative duties, she continues to work as a CDS when needed. I identified that oncology was my weakest area and she approved my time to spend at the Cancer Center’s weekly nursing study group… I appreciate that she fosters the growth of new staff.”
• “Cathy also spends time researching for the best practice when questions arise regarding CDI policy and procedures and then uses this information to provide reports to upper management.  She has developed a strong supportive relationship with our Coders and actively encouraged working as a team.”
• “Cathy has been involved with this program since it started over 10 years ago.  She has been instrumental in developing and leading a successful CDI program with excellent outcomes.”
• And from her hospital’s Chief Medical Officer, “She has both enhanced our system and created a valuable team that we now cannot envision not being in place and leading us.”

Congratulations, Cathy!

Meet Robert

Robert Hodges

Robert Hodges developed a query program at his facility that became a model for a national program. The reason for his nomination is summarized here:

Robert developed a CDI program at the Aleda E. Lutz Medical Center and because of his experience and knowledge, was instrumental in developing a national VHA standardized provider query process.  The VHA Provider Query process includes a practice brief and query forms that were developed to assist all VA Medical Centers nationwide with implementing a clinical documentation improvement program.

He presented on the new process, the query forms, and query tracking to provide CDI education to all VA Medical Centers during a national VHA satellite broadcast.

Congratulations, Robert!

Meet Dee

Dee Schad

Dee Schad is the president of her local ACDIS Chapter (Southern Indiana/Louisville, Kentucky) where she ensures the members receive on-going relevant education and networking opportunities. In part, her nomination included this description of Dee:

“Dee is passionate about clinical documentation improvement.  When she speaks about clinical documentation, there is a gleam in her eye and excitement in her voice.  She is very knowledgeable and experienced in the field of clinical documentation improvement and conveys a level of professionalism that extends beyond many individuals.  Even at her organization’s department level, Dee understands the current challenges of the field and helps to continue to develop the practice of clinical documentation improvement. ”

Congratulations, Dee!

Editor’s Note: Say hello and congratulate Cathy, Dee, and Robert in San Diego at the 5^th Annual ACDIS Conference in May.

CDI specialist orientation (more CDI Talk inspiration)

One of the repeated conversation themes on CDI Talk is how to orient a new staff member (within an existing program), or how a small program can start its own CDI efforts and train its own staff. Parallel to those conversation threads are participants’ real hunger for more avenues and sources of education.

Let’s look at some of ACDIS’ online poll data to set the stage:

• July 2011: How many total years of professional experience do you have in healthcare (CDI, plus other)?
• 20 years or more, 60%
• November 2009: How long did it take you to get up to speed as a new CDI specialist?
• 3 to 6 months, 32%
• 6 to 12 months, 34%
• June 2011: How long do you think it takes to achieve an “expert” level of proficiency as a CDI specialist?
• 2 years, 35%
• 3 years, 22%.

And here’s one  final on-line poll data point to help me answer the question as to whether CDI managers are actually providing enough training to new staff members:

• January 2011: How long is your training period for new CDI specialists?
• 12%, 2 weeks
• 22%, 30 days
• 30%, 31 to 60 days
• 20%, 61 to 120 days
• 12%, approximately 6 months
• 3%, less than 6 months

It seems to me that those who indicated that it takes six months or more to get up to speed need more training than what I commonly consider necessary as part of orientation.  This data suggests that what is these new CDI specialists need is more of a mini-college training program.

Obviously there is a rather significant challenge—how to provide the level of knowledge and training along with the

(Image via Homeclick) It is a sink that is made so fish swim in it. Get it? Sink or swim.

appropriate mentoring to actively promote and support the new CDI specialists so they can succeed. Of course, there is always the consultant option which proves to be relatively expensive. Plus, a ‘mature’ program should not need to rely on such an expensive option for new staff orientations. At the opposite end of the spectrum is the ‘sink or swim’ method.

Thankfully, home grown and self-supported possibilities exist to constitute a middle ground between these two options. At the very least, facilities should implement an orientation or mentoring process where the experienced individual’s guidance can make a huge impact.

I believe the biggest challenge facing those hoping to implement a CDI orientation program comes from a lack of targeted, written learning resources. I consider one of the largest draws for ACDIS membership stems from the need for learning, resources, and accessibility to a community of knowledgeable and supportive peers. ACDIS provides such a community, with a quickly growing resource base. (If you’re a member, you ought to know. If not, go look at every part of the ACDIS home page).

In addition, ACDIS offers a few helpful handbooks and guides that can be re-purposed for orientation, such as:

• The 2012 CDI Pocket Guide
• The CCDS Exam Study Guide
• The CDI Specialists Handbook, second edition
• The Physician Queries Handbook

Furthermore, the only independent (i.e., not part of a consulting package) seminar I’ve found is HCPro’s CDI Boot Camp. While the total cost (fee, travel, hotel) may be prohibitive for many there is also the online version as an option. Again, a mature CDI program ought to be able to handle at least some of the orientation process internally.

Even with the valuable resources of ACDIS, some holes in new staff orientation remain. AHIMA and AHA’s Coding Clinic for ICD-9-CM provide further guidance, but even those resources do not cover everything. Several major elements of an orientation program are not addressed by the resources mentioned.  Just to get started, how about:

• Creating a tool that outlines in detail basic competency and knowledge expectations for the novice CDI specialist. This tool should also list areas for mid-level and advanced achievements to give new CDI staff a set of expectations for continued professional growth. There are some examples in the Forms & Tools Library, in the policies and procedures section (search for “staff orientation checklist), but not at the detail I envision.
• Curating a collection of vital subject articles and references. (Review the CDI Journal archives, the ACDIS Blog, and the Helpful Resources links just to get started on this collection. Add in other professional organizations and their publications such as the National Institutes of Health, AHIMA, AMA, and others and this would be a one-stop database of useful CDI knowledge.)
• Creating an outline of topics that the new CDI specialist needs to master before achieving their initial competency. Further, this outline ought to provide enough detail and referenced sources to serve as a complete training program guide.
• Sources would likely include the books and articles mentioned immediately above, along with sections of widely accepted texts such as coding guidelines, Faye Brown, and medicine texts like the Merck Manual.

Before starting to collect all those articles and tools, though, I should probably determine the basic elements of an orientation program! Below I’ve listed a few resources online which discuss this, including:

• The five key elements of a good orientation program
• The Community Tool Box: Developing Staff Orientation Programs
• Making New Employee Orientation a Success

After reviewing these, I must confess that my definition of orientation varies from those discussed above.  Still, several points are important to keep in mind to successfully bring a new staff member up to speed in the CDI world:

• Provide structured, purposeful training
• Offer a straightforward sequence of topics or activities to enable learning
• Give new staff members a written agenda complete with goals and measurable objectives
• Provide ongoing, two-way feedback and evaluation
• Supply appropriate resources and support
• Actively integrate the new person into the team
• Celebrate and welcome the individual and his/her accomplishments as they gain proficiency in their new role
• Pair new staff with an experienced mentor and provide oversight of their engagement
• Offer engaging, interactive, as well as some self-directed education

However, as mature and professional learners, CDI specialists must be responsible and accountable for their education and success.

Honestly, for a new or developing program that has to add or replace staff, the right consultant is worth the money.

At some point CDI programs need to be able to hire new staff and train them in-house. Creating a comprehensive training program does require a lot of effort and maybe it is work that some of you have already done?  If so, why duplicate work? Let’s see if we can compile a  “best of” list of what program components others have found successful and create a tool that we can share. Post your information here to the blog, e-mail me, or contact Associate Director Melissa Varnavas mvarnavas@cdiassociation.com

Q&A: How to resolve DRG confusion

Q: Confession. I am very frustrated. I am fairly new to CDI. I have a nursing background. I’m trying to understand how

Learning how to navigate the coding and DRG landscape can be daunting. Don't worry. Others have had to learn this too. Ask for help and know you are in good company.

the coding and DRG system works. But when I look up a diagnosis in the DRG Expert in the alphabetic index to diseases it is not listed as I would expect it to be.

Take for example, bradycardia. It is not listed under that term or arrhythmia.  Yet, it is listed under cardiac arrhythmia. For another example, how about anorexia? The only listing is anorexia nervosa—not unspecified.

I also find it ironic that I cannot infer what a physician is stating (it has to be documented precisely) but when I have to look up a term I have to guess its meaning.

Do you have any advice for me?

A: Your frustration is very common among new clinical documentation improvement (CDI) specialists.  The publishers of the DRG Expert did not include the same type of Index to Diseases that you would find in Volume I of an ICD-9 code book—probably to save space. The Index to Diseases alone in my code book is 380+ pages.

This is one reason that during the CDI BootCamp I mention so many diagnoses as we review Medicare Severity Diagnosis-related groups (MS-DRGs) in a major diagnostic category (MDC) and either have you highlight them or write them in, because I, too, had exactly the same issues you are having.

Every CDI team should also have a coding book in their department to use as a reference (ask your facility HIM department if they have an old one you can have), especially if you do not have access to the encoder (coding and reimbursement software), which would let you look up whatever you wanted—however, even that has limitations, because search terms often use “coding language” rather than the everyday language of clinicians.

As far as your comment regarding the irony of the situation, all I can say is “Right on, girl!”  It is the reason we have taken on this role. We were hired to become the “translators” or “interpreters” to ensure that the clinical language matches the language needed by the coders. Acquiring the skills to understand both of these languages, along with the ability to translate from one to the other, is what makes us, as CDI professionals, unique.

As a final note, I just want to share that my very first DRG Expert was COVERED from end to end with handwritten notes, stickies, and slips of paper. I used this book for three years, copying my info into each new edition until I was granted encoder access. Every time I asked a coder where to find something I wrote it in the book—especially those diagnoses that had really strange “code” descriptions.

I hope that I can assure you, that by this time next year, you will have many of these coding terms memorized.

I tell all my CDI BootCamp students that there is a long learning curve to this position, so don’t worry. While some people catch on quickly, for most it may take up to six months before that proverbial light bulb finally goes on and frequently it takes up to a year to feel confident in the role.

Don’t get discouraged. Most CDI specialists will tell you the same thing! Before you know it, you will find yourself sitting in traffic, converting license plate numbers into DRGs or diagnosis codes.

2012 CDI professionals’ salary survey

The 2012 CDI professionals’ salary survey was sent to ACDIS members on Tuesday, January 24. In less than 24 hours more than 400 people participated. In 2008, 132 individuals completed the survey. In 2009, responses doubled to roughly 300. In December of 2010, nearly 900 people responded.

I restate these numbers for two reasons. First, I want to encourage all those working in clinical documentation improvement to participate. The larger the pool of responses, the more valid the data. If you are a CDI specialist who reviews medical records please participate. If you are a CDI manager or CDI program director, please participate. If you are a physician advisor whose primary responsibility is oversight and assistance for CDI efforts at your facility, please participate.

Second, over the past few years these numbers have illustrated an interesting point, one which we have internalized anecdotally; the CDI profession is growing. While that may seem like an obvious observation, there have been discouraging stories from around the country of late about CDI programs being dismantled, their duties coupled with those of case managers or quality improvement, or worse, abandoned altogether.

In speaking with consultants and many of you, we have pondered the reasons as to why some healthcare systems seem to be ramping-up their documentation improvement efforts, hiring upwards of 20 CDI specialists, while others simply turn their back on CDI.

Some suggest that facilities have too many initiatives underway right now; they have too much to worry about, too many people to hire to accomplish other, higher priority tasks. They worry over compliance with HIPAA’s 5010 technology initiative, implementation of computerized physician order systems and electronic health records, never mind ICD-10 preparation and training and the rest of the worries associated with healthcare reform.

Others suggest that the programs that closed did not do a good enough job analyzing their CDI program’s effectiveness and communicating that success to facility managers. (Read the blog posts “Asset or Liability” by Glenn Krauss or “The Importance of Metrics and Goals on Behavior” by Donald A. Butler, among other great information previously shared here.)

“Once the case-mix index stops improving administrators stop seeing the value in the program,” one CDI specialist indicated during a telephone conversation. We commiserated, talked about all the other ways CDI specialists’ efforts affect facility prosperity and discussed the role of CDI programs will play in the onslaught on changes coming to the healthcare landscape.

I believe that despite these “stories” of short-sightedness the profession of CDI truly is growing. For each tale of sorrow, I have heard of program expansion into areas of outpatient and emergency clinical documentation, expansion and collaboration between CDI professionals and other internal departments such as audit preparation and physician education for the coming ICD-10 needs. Now, all I need is the data to back this up.

Please take a minute to participate in this year’s 2012 CDI professionals’ salary survey.

Oh, by the way, the other great thing about the salary survey is that it gives you a benchmark against which you can compare your salary to those performing similar tasks. Does anyone out there think it might be time for a raise?

Here is a sneak peak of what people indicated they earn thus far.