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Two important announcements regarding the CCDS exam

CCDS certification discussed during latest Quarterly Membership Call

CCDS certification.

Deadline for CCDS exam at ACDIS conference in Las Vegas
Friday, April 11
is the deadline to apply for the Certified Clinical Documentation Specialist (CCDS) exam administered at the ACDIS conference in Las Vegas, Friday, May 9. You must register for this exam in advance. Late arrivals or walk-ins will not be admitted to the exam room.

To apply, download the application, complete it and return it to Penny Richards by one of the contact methods listed on the application. Be sure to mark the top of the application “LAS VEGAS EXAM.”

Contact ACDIS Member Services Specialist Penny Richards, for additional information.

ICD-10 exam update delayed to January 1, 2015
As previously announced, the ACDIS Certified Clinical Documentation Specialist (CCDS) exam will be changing to reflect coding guidelines under ICD-10-CM/PCS. After consideration, the CCDS Exam Committee decided to shift the effective date of the exam change to January 1, 2015. The Committee believes it is appropriate to delay exam changes until the ICD-10-CM/PCS system is in use and CDI professionals have had a chance to work in it for a few months.

The current ICD-9-CM version of the exam will remain in place for the remainder of this calendar year. The CCDS Exam Study Guide will be available at the same time the new exam takes effect and is otherwise applicable for anyone studying to sit for the exam through December.

Contact ACDIS Member Services Specialist Penny Richards with questions.

Full/part-time coding instructors sought

Do you have what it takes to join the HCPro team of coding and documentation improvement Boot Camps? Let's see a show of hands!

Do you have what it takes to join the HCPro team of coding and documentation improvement Boot Camps? Let’s see a show of hands!

HCPro seeks coding education specialists to serve as instructors for ICD-10-related boot camps. Enjoying teaching and education are a must, as are excellent verbal and written communication skills. As one of the most successful coding programs in the U.S., our instructors are considered some of the best in the industry. HCPro only seeks the most experienced within the field of coding education to add as team members.

Coding instructors are home-based; full-time positions require approximately 50% travel and part-time adjunct positions require at least 4-6 weeks travel per year. All successful candidates must be dynamic public speakers, have extensive expertise in ICD-9-CM coding, have significant inpatient coding experience, and have a minimum of CCS certification. Candidates who hold a bachelor’s degree, are AHIMA-approved ICD-10-CM/PCS trainers, advanced degrees (RHIT, RHIA), and have significant adult education experience are preferred.

Send resume and cover letter to Rebecca Hendren via email at

Looking for CCDS continuing education credits? Use your ACDIS membership

CCDS certification discussed during latest Quarterly Membership Call

ACDIS offers multiple ways to maintain CCDS CE credits.

We recently received an inquiry from an ACDIS member who, unfortunately, was not able to attend this year’s ACDIS National Conference and came up short on her needed Certified Clinical Documentation Specialist (CCDS) continuing education (CE) credits.

There are a number of ways to obtain CE. (For complete information about re-certification please visit the webpages dedicated to the topic on the ACDIS website.) Many ACDIS local chapter events offer CCDS credits and most are extremely reasonably priced between $25-$45 depending on whether you belong to the chapter or not.

Additionally, some of the CE courses you’ve already taken through your facility or related association (AHIMA, ANCC, ACMA) may qualify for CCDS CE too. (There is a list on the re-certification tab of what is acceptable. If you have any questions, contact ACDIS Membership Services Director Penny Richards at

In addition, your ACDIS membership provides up to eight CE credits per year should you choose to take advantage of them. The Quarterly Conference Calls each offer one CE and the quarterly CDI Journal also offers one CE for each issue.

Members are notified of the date and time for the live conference calls but you need not listen live to obtain the CE; simply visit the ACDIS site, look for the conference call tab on the left navigation bar, listen to the streaming audio, and take the related survey. A certificate will be mailed to you once you complete the survey.

Similarly, ACDIS members can read the CDI Journal and take the short, 15-question content-related quiz, and receive CE credits for their efforts. The quiz is typically posted two weeks after the Journal content. Please remember, however, the CDI Journal is a web-based PDF document and members must login to their ACDIS account to access it.


2013 CDI Salary Survey open

In ACDIS’ 2012 CDI Salary Survey, the majority (26%) of respondents earned $60,000–$69,999 annually. However, those earning $70,000–$79,999 rose four percentage points—from 16% to 20%—over previous surveys.

How will pay ranges shift in 2013? There’s plenty of speculation related to remote and travel CDI as well as the increased demand for experienced professionals. Your participation in this year’s survey will provide concrete results. Please take a few minutes to participate and share your experiences. Portions of the data will be provided in CDI Strategies and the full report will be provided to ACDIS members.

Guest Post: AHIMA director offers CDI insights

AHIMA releases CDI toolkit.

Endicott says increasing healthcare complexity requires CDI input.

By Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA

Clinical documentation is the foundation of all aspects of healthcare, including data analysis, research, communication between caregivers, reimbursement, and most importantly, quality patient care.
The concept of clinical documentation improvement (CDI) is not new; however, the increasing complexity of the healthcare reimbursement system, quality initiatives, and the transition to ICD-10-CM/PCS put CDI programs in the spotlight. This article provides a high-level view of CDI programs, qualifications for CDI professionals, and future opportunities for this growing profession.
CDI programs
The purpose of a CDI program is to initiate concurrent and/or retrospective reviews of inpatient records to identify conflicting, incomplete, or nonspecific provider documentation. These reviews usually occur on the patient care units or remotely via the electronic health record (EHR).
The goal of these reviews is to identify clinical indicators that support the assignment of ICD-9-CM diagnosis and procedure codes. CDI professionals often use written queries in the health record to accomplish this goal. They may also use verbal and electronic communications. These efforts result in improved documentation, coding, reimbursement, and severity of illness/risk of mortality classifications.
Although CDI programs traditionally occur in the acute inpatient setting, they are being implemented in other healthcare settings as well, including acute rehabilitation hospitals and skilled nursing facilities.
CDI professionals
Individuals working in a CDI role need very strong clinical and analytical skills as well as expertise in coding. Most commonly, CDI professionals have several years of experience in inpatient coding or a nursing background. The essential coding skills that these individuals must possess include the following:
  • In-depth knowledge of ICD-9-CM guidelines and conventions
  • Access to and awareness of pertinent AHA Coding Clinic references
  • Understanding of the MS-DRG reimbursement system, including relevant MCCs and CCs that affect the MS-DRG assignment
CDI professionals must communicate effectively, both verbally and in writing, with clinical staff. CDI professionals routinely communicate with providers about documentation improvement and education, so it’s important that they are well-spoken and professional at all times to build trust and rapport with the clinical staff.
CDI professionals typically hold one or more of the following credentials:
  • Clinical Documentation Improvement Practitioner (CDIP)
  • Clinical Documentation Specialist (CCDS)
  • Registered Health Information Administrator (RHIA)
  • Registered Health Information Technician (RHIT)
  • Certified Coding Specialist (CCS)
Looking ahead to ICD-10-CM/PCS
The United States will transition from ICD-9-CM to ICD-10-CM/PCS on October 1, 2014. This transition is far more complicated than the annual code update to which coders and CDI professionals are accustomed. ICD-10-CM/PCS codes bring with them increased specificity, laterality, updated terminology, and new and revised guidelines. Hospitals should perform a gap analysis of physician documentation to identify opportunities for education and documentation improvement.
CDI professionals are the ideal individuals to educate physicians about the documentation requirements for these new code sets because they’ve already built trust and rapport with the clinical staff. CDI staff should be fully trained in both ICD-10-CM and ICD-10-PCS. This includes receiving in-depth training on the ICD-10-CM/PCS guidelines.
Future roles
Quality documentation is necessary in all healthcare settings. Outpatient settings, such as clinics, physician offices, and ambulatory surgery centers can reduce denials and improve data quality by employing CDI professionals to review records and identify deficiencies.
Other non-acute care settings can also benefit from a CDI program. These include long-term care, skilled nursing, home health, and rehabilitation centers. The future is bright for CDI professionals.
Editor’s Note: Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, is a director of HIM practice excellence at the American Health Information Management Association in Chicago. E-mail questions to Endicott at
This article was originally published on

Job description of the new CDI specialist

Do you know what is expected of you? Do you have clearly communicated goals for how to grow professionally?

Do you know what is expected of you? What role will CDI specialists be asked to play in 2013 on into the future?

Editor’s Note: Catch Glenn Krauss’ presentation “Migrating to outpatient ambulatory CDI” during the ACDIS 6th Annual Conference in Nashville, today, Thursday, May 23, at 10:45 a.m.

CDI is an ever-changing and ever-evolving profession. The following is a sample job description and representation of skills required of the “new” CDI specialist; a staff member who can respond to the transformation of healthcare from volume based fee-for-service delivery to a model vested in quality, value, efficiency, and outcomes; a staff member who represents the evolution of CDI efforts beyond the realms of reimbursement.

Job description

Review of paper and electronic health records for accurate and complete documentation of all relevant diagnoses, procedures, and ancillary treatments.

Applicants must demonstrate a willingness to maintain awareness of the business of medicine and transitional healthcare changes, including but not limited to value-based purchasing, bundled payments, accountable care organizations, and the readmission reduction program.

Must be devoted to ongoing, continuous learning in clinical medicine; practical understanding of ICD-10 and ability to educate physicians on the merits of preparation as the best practice strategy for ICD-10 readiness in their office and hospital setting; relevant updates and happenings in the business of medicine directly impacting physician’s, updates from CMS carriers effecting physicians such as billing, documentation, and coding guidelines and policies.

Flexible hours required in order to facilitate face-to-face meetings with physicians in the hospital and their private practice.

Applicants should recognize that CDI is a business with the CDI specialist representing a “business within a business,” constantly striving to think outside the box with continuous quality improvement efforts to better the business while seeking greater return on investment. Measurement of return in investment is the extent to which clinical documentation:

1)      accurately reflects and reports the patient’s severity of illness equating to intensity of service

2)      effectively demonstrates physician clinical judgment and medical decision making in support of medical necessity

3)      promotes continuity and specificity of clinical documentation throughout the record, including progress notes reflective of the “progress” of the patient

4)      facilitates complete discharge summaries in promotion of post-acute care and facilitation of orderly handoff to patient’s primary care physician



  • Familiarity with MS-DRGs and the Inpatient Prospective Payment System (IPPS), including new CMS guideline of key elements including clinical documentation of what constitutes an inpatient admission (see 2014 IPPS proposed rule)
  • Strong clinical knowledge and demonstrated commitment to maintaining relevancy in clinical field
  • Familiarity with ICD-9-CM and ICD-10-CM Official Coding Guidelines
  • General knowledge of what constitutes a complete and accurate record—i.e., complete and thorough clinical documentation beginning with the emergency room reflective of clinical presentation of patient; reason for admission that clearly establishes and meets medical necessity criteria; need for continued stay in the hospital including response to treatments, interventions, and outcomes; complete and accurate discharge summary.
  • Practical knowledge and understanding of official physician E & M guidelines and documentation requirements in support of proper E & M assignment and establishment of medical necessity
  • Effective ability and willingness to communicate benefits of complete and accurate documentation to physicians relating to their daily practice of medicine
  • Commitment to continuously increasing knowledge in and familiarity in constantly changing updates in the business of medicine directly impacting physician’s business of the practice of medicine today and in the future
  • Demonstrated ability to obtain documentation relevant to denials avoidance related to the Recovery Audit program, the Comprehensive Error Rate Testing (CERT) program, and other audit programs, recognizing and promulgating to physicians the synergies of clinical documentation for both the physician and the hospital.
  • Ability to review medical necessity denials and provide constructive feedback to providers
  • Ability to work with all physician specialties in clinical documentation improvement initiatives, effectively tailoring learning and education opportunities to each physician specialty on an “as you go” basis.
  • Ability to collaborate with case managers to collaboratively capture patient severity of illness and intensity of service to ensure medical necessity.
  • Willingness to register for and attend all relevant ICD-10 and other billing/coding related educational offerings by CMS contractors, effectively sharing with physicians on a need to know basis, integrating key concepts and elements as they relate to clinical documentation improvement into daily routines and practices of CDI.
  • RN and/or RHIA required; CCDS and/or CCS strongly preferred

CDI and Readmissions: A primer in the age of value-based purchasing

Capture appropriate documentation for coding postoperative complications.

CDI staff can help improve documentation related to readmissions.

By now you should be aware of CMS’s readmission initiative as part of value based purchasing (VBP).  Medicare fee-for-service patients, or VA patients, who are admitted for any reason within 30 days of a discharge with a principal diagnosis of acute myocardial infarction, heart failure, or pneumonia are included in this initiative.

All Medicare reimbursement (not just for this patient cohort) is reduced up to 1% in fiscal year (FY) 2013 (goes up to 2% next year and 3% in FY 2015), depending on how effectively hospitals manage readmissions.  While there are exclusions (for death, AMA, certain planned readmissions, younger patients, and patients with AMI who are discharged the same day) CMS does not differentiate between related and unrelated diagnoses, or preventable versus necessary admissions.

Each hospital’s penalty for this year has already been posted publicly and is readily available for review.  You should look up your hospital’s penalty, if you haven’t already. A significant number of major institutions were penalized the maximum, 1%, but they contend that they are being penalized for serving the underserved (homeless, uninsured, etc.) who tend to cycle through the hospital rather than being managed in the community.

The first admission is called the index admission. Regardless of the number of readmissions within the 30 days following discharge, there is only one index admission and only one penalty for readmission. When the 30 days expire, the next admission is a new index admission. However, an index admission for heart failure and a readmission within 30 days for pneumonia is counted as both an index admission for heart failure and an index admission for pneumonia. In addition, same day readmissions for the same problem are incorporated into the index admission.

CMS is expected to add new measures to the readmissions initiative by FY2015, most likely COPD, CABG, PTCA, and other vascular conditions. At that point the maximum penalty will be 3%.

Let’s hope CMS stops there!

Separate from the readmissions initiative are potentially preventable readmissions. Potentially preventable readmissions are those admissions due to premature discharge, incomplete care, or inappropriate transfer, even if the readmission occurs at a different hospital than that of the index admission. CMS expects hospitals to complete care that should have been taken care of on the first admission. Quality Improvement Organizations (QIO) who review records for CMS look at readmissions to see if they may be related. Any admission within 30 days of the discharge date of the index admission is considered, but the QIO may deny the readmission regardless of time since the index admission particularly if there is a “chain” of admissions for the same problem.

APR-DRGs, a 3M™ product, are used to determine if the conditions necessitating the dual admissions are clinically related. A clinical relationship is presumed to exist if there is:

  • A continuation of recurrence of the problem causing the index admission, or a closely related condition
  • An acute decompensation of an acute condition that may not have been the reason for the index admission, but might reasonably have been related to care during or just after the index admission
  • A medical readmission for an acute complication that might have been related to the care during the index admission
  • A readmission for surgery to address a continued or recurrent problem that caused the index admission
  • A readmission for surgery to correct a complication caused during the index admission

The Office of the Inspector General (OIG) also has its eye on same-day readmissions. It was identified as a target area in the 2013 OIG Work Plan. A Medicare patient’s readmission for symptoms related to or for evaluation or management of the first stay’s medical condition will result in the hospital’s only receiving one DRG payment, combining the original and subsequent stays into one claim.

As CDI specialists, we should be looking at how documentation affects readmissions.  Look for documentation that:

  •  Supports planned readmissions
  • Clearly defines the plan of care and the discharge plan
  • Shows continuity of care and high quality of care for all diagnoses identified during the stay

Look at how principal diagnoses are documented and sequenced. Simple pneumonia triggers a targeted readmission measure, but aspiration pneumonia does not.  See the opportunity?

Review documentation for clinical indicators that might trigger “post-hospital syndrome,” leading to early readmissions:  sleep disturbances, malnutrition and delays in feeding, deconditioning, multiple changes in medication, inadequate or excessive sedation, and other stressors of hospitalization.

Talk with your case managers and your physicians when you see this evidence of potential problems.  As clinical documentation specialists, get involved clinically and not only improve our numbers and public profile, but improve the care of our patients.


Celebrate National Nurses Week May 6-12

Florance Nightengale

Florance Nightingale

This week, Kris Cilona, RN, BSN, CCDS, at Mercy Medical Center in Canton, Ohio, will celebrate National Nurses Week by creating and displaying a poster about how nursing documentation affects CDI efforts.

“I want the nursing staff to understand what CDI is, what it is the CDI specialists are looking for in the charts, and how their documentation can help us to substantiate our queries,” Cilona wrote in a CDI Talk post.

Supported by the American Nurses Association (ANA), National Nurses Week takes place annually from May 6, (also known as National Nurses Day) through May 12, the birthday of Florence Nightingale, the founder of modern nursing. This year, the ANA chose the theme “Delivering Quality and Innovation in Patient Care.”

Just as ACDIS sponsors national CDI Week and encourages CDI professionals to spread the word about the CDI profession, the ANA provides a list of suggested activities from visiting politicians to conducting media outreach to hosting celebratory events within facilities.

As many CDI specialists proudly bear their RN backgrounds, ACDIS proudly solutes the efforts of all nurses—those who chose to move to an exciting new CDI career as well as those who choose to at the bedside of sick patients every day.

We encourage you to reach out to your counterparts and share their excitement and, like Cilona, tell them how much their daily work means to you and your CDI efforts.

As Cilona says, “Happy Nurses Week to everyone coders and nurses alike!”

2013 CDI Professional of the Year nominations sought

Nominations open for CDI Professional of the Year.

Dear ACDIS member,

It’s time to gather nominations for the 2013 CDI Professional of the Year, to be awarded at the sixth annual ACDIS Conference in Nashville, May 21-23, 2013.

In addition to the CDI Professional of the Year, ACDIS will also award two members with the 2013 Recognition of CDI Professional Achievement awards.

These awards are based on your input. You are the ones who work side-by-side with outstanding colleagues who represent the best of the profession. You know them and understand the critical role they play in documentation excellence, accuracy and integrity of reimbursement, quality of care, and physician education. We’re looking for CDI professionals who have made a big impact in their own facility, among their local ACDIS chapter, or on the broader industry as well.

Please click this link, and download the nomination form. Fill it out and email it back to me by Friday, February 8, 2013.

We are excited to find the 2013 CDI Professional of the Year and will be even more excited to introduce that person to you in Nashville next May.

Best regards,
Brian Murphy, CPC
Association of Clinical Documentation Improvement Specialists (ACDIS)
Danvers, MA
781-639-1872, ext. 3216

CDI ‘superstar’ stories continue

In the fall we asked ACDIS members to explain what it takes to be an exemplary CDI specialist, to excel at not only medical record reviews, but also at incorporating the underlying purpose of CDI efforts into even seemingly mundane, everyday tasks. We heard from quite a few folks who shared some sound, sage advice and complied it in the January 2013 edition of the CDI Journal.

In fact, we received such a tremendous response that we thought we would continue publishing these “Superstar Stories” monthly throughout 2013. To share advice of your own, please shoot me an email at and include “Superstar Stories” in the subject line. Please include your name, title, facility name, city and state. Please also indicate if you are a board member or chapter leader (or other affiliation you’d like me to list). We’d also love to have your photo.

Any CDI topic is welcome, including smart documentation tips, team building strategies, training and education ideas, or how to be an effective leader.