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Tip: Take a closer look at POA reporting guidelines

The 2017 ICD-10-CM Official Guidelines for Coding and Reporting brought many changes and updates for coders, and present on admission (POA) reporting was not excluded. Completely understanding POA guidelines is necessary for any inpatient coder or CDI specialist.

Per the Guidelines, POA conditions are defined as those present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, such as an emergency department, observation, or outpatient surgery, are also considered POA. A coder would assign the POA indicator to a principal or secondary diagnosis.

Think of understanding POA indicators as “part two” of understanding coding rules, says Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, and coding regulatory specialist at HCPro, a division of BLR, in Middleton, Massachusetts.

“Once the codes have been assigned for an inpatient record, a coder then must go back and evaluate each one for the appropriate indicator,” Commeree says. Also important to remember is there is no required time frame that a provider must document a condition for it to be considered POA, so CDI professionals can still clarify conditions as POA through their efforts, as well. It could take several days for a provider to assign a diagnosis. Because it may take a provider several days to arrive at a diagnosis does not mean that the condition was not POA. Determination of whether the condition was POA is based on the Guidelines and on the provider’s best clinical judgment, Commeree says, since according to the Guidelines:

“In some clinical situations, it may not be possible for a provider to make a definitive diagnosis (or a condition may not be recognized or reported by the patient) for a period after admission.”

The Guidelines also state that if at the time of code assignment, the documentation is unclear as to whether a condition was POA, it is appropriate to query the provider.

“If we’re not sure if it was POA—it wasn’t explicitly documented as POA, diagnosed prior to admission, or diagnosed during the inpatient admission but seems POA by indication of signs and symptoms—it’s not up to us to decide. A query to the attending provider is the best course to take.”

Editor’s Note: This article originally appeared in JustCoding. To access the original article, click here.

Book Excerpt: Teamwork makes the dream work


Elizabeth Lamkin, MHA, ACHE

by Elizabeth Lamkin, MHA, ACHE

CDI specialists do not work alone. They form a team with case management (CM) and physicians for concurrent documentation analysis and improvement. The case manager advises the physician on patient status, the CDI specialist ensures the documentation reflects the status and care, and the physician advisor is there to support CM and CDI if there is conflict with a physician or clinical staff. The physician advisor can take advantage of every interaction to transform potential conflicts into teaching opportunities.

For example, a patient is scheduled for surgery as an outpatient but the surgery is on the inpatient-only list (CMS, OPPS final rule, 2016). The surgery scheduling department checks the inpatient-only list and notifies the physician that CM is going to review for status. The surgery department then alerts registration, which notifies the CM, who checks to make sure all requirements for the inpatient surgery are met. The CM advises the physician on correct status and, ideally, the physician follows the CM’s advice.

The CDI specialist checks the documentation for compliance and coding, and queries the physician if the documentation is incomplete. If the surgeon refuses to change or complete the documentation, the CDI specialist escalates the issue to the physician advisor. The physician advisor contacts the physician and explains the reasons for inpatient status and additional documentation. The surgeon completes the documentation as requested. If these steps are completed, coding and billing will clearly know what claim to drop without requiring a bill hold and clinical review.

Additionally, this three-part team of CDI specialist, CM, and physician advisor are able to gather real-time feedback on whether the electronic health record (EHR) is user-friendly, and report findings back to the executive team and IT. In some cases, problems with the EHR are simply user error or lack of training, and the CDI specialist can play a role in teaching providers to use the EHR.

Throughout this process, the HIM department works with CDI and supports physicians through functions such as timely transcription and ensuring chart completeness. Together, CDI and HIM look to ensure appropriate orders, signatures, and all required elements of the medical record. This includes ICD-10 coding and documentation to monitor ICD-10 compliance. HIM has traditionally been responsible for the organization of the medical record but now must have a collaborative relationship with IT and the EHR vendor to ensure the record works well for all stakeholders.

Finally, HIM will also review the medical record upon discharge for completeness. The next step is to code the record for payment. If all the previous steps in revenue cycle have occurred correctly—required forms are in place, patient status is clearly documented with a care plan, and discharge status is clear and accurate—then the coders should have all the elements needed for accurate coding. There should be very few physician queries from HIM if coding is clearly supported through documentation. Getting all of this right while the patient is in the hospital will facilitate accurate coding and produce a clean claim to avoid back-end corrections and delayed billing.

Editor’s note: This article is adapted from The Revenue Integrity Training Toolkit by Elizabeth Lamkin, MHA, ACHE. Lamkin is CEO of PACE Healthcare Consulting and specializes in system development, quality and billing compliance. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Conference Corner: Make time to check out the Poster Session at the Conference in Las Vegas

By Penny Richards, CCDS Coordinator and Member Services Specialist

2016 Poster Session

2016 Poster Session

Along with a dizzying number of education sessions at the ACDIS Conference in Las Vegas next month will be the annual Poster Session. These science fair-style presentations allow a selected group of your colleagues to present their CDI team and facility’s challenges and success stories, condensed onto a poster. Posters will be on display throughout the conference in the Exhibit Hall.

Presenters will be on hand during the morning break on Thursday, May 11, (10:15 to 11:15 a.m.) to talk to you about their poster and answer your questions. You’re sure to come away from the Poster Session with great ideas to incorporate into your CDI program to help build your own success story.

2016 Poster Presenters

2016 Poster Presenters

Here is a list of topics you’ll find at this year’s Poster Session:

  • CDI Report Card: Physician CDI Education
  • How to Avoid a Query Initiative: Educating the Physicians
  • Implementation of the Stop Sepsis Collaborative
  • CDI 2.0: Education for the Newer CDI
  • CDS Competency Validation
  • Putting the PSI in CDI
  • Key Chart Reviews Using SharePoint
  • Improved SOI and ROM Documentation
  • Provider Perspective on Charting Compliance and Query Success
  • Pediatric Malnutrition
  • CDS Coverage and Query Delivery
  • Remote CDI Challenges and Solutions

    Browsing the posters

    Browsing the posters

  • Shared Note Query in EPIC
  • Growth and Success at Tidelands Health System
  • Building a Successful CDS Team
  • Finding Data Hidden in Obstetrics and Prenatal Records
  • Career Ladder: Review Assignments by Units
  • A Retrospective Denials Review
  • Strategies to Improve Provider Query Response Rates
  • Out DRG Analysis and Review Taskforce (DART).
  • Our successful CDI/HII (Health Information Integrity) Remote Team
  • Transition from Traditional CDI Practices to Innovative CDI Practices
  • Shift from Regional to a System Approach to CDI
  • CDI in the Rehab Setting
  • Physician Engagement with TEMPO Board Rounds
  • MS-DRG Groupers Assigned to the MDC 24
  • Revitalizing a CDI Program to Promote Orientation of New Staff
  • Daily CDI Huddle: Team Meeting
  • Oncology Documentation: Improving SOI and ROM
  • Development and Implementation of a CDI Ladder
  • Impact CDS Impact on Quality Reporting and Documentation Accuracy
  • From Failing to Exceeding Goal in Three Months
  • Financial Impact of CDS in Critical Access Hospitals
  • Candyland: A Fun Look at CDIs and Physicians Engagement
  • Complications of Care: A Retrospective Review

You will find a list of all of the posters in your conference bag so you can make notes of which topics you find particularly interesting for follow up after the conference.

We will take photos of each poster and put them on the ACDIS website after the conference. We will also post a one-page description written by the presenter, including their contact information, so you can reach out for more helpful information about their topic.

Maybe you will present your success to conference attendees in 2018!

Conference Conversations: What are ACDIS speakers looking forward to most?

ACDIS 2017

ACDIS 2017

“It’s in Vegas. Need I say more?” jokes William E. Haik, MD, FCCP, CDIP, who presents “Sepsis: 1, 2, 3—RAC Attack!” on Day 1, in Track 1, at 1:45 p.m.

Hardly a week goes by without a mention of sepsis in the medical literature, whether peer-reviewed scientific journals or non-peer-reviewed medical publications. Recently, more evidence has surfaced that seems to support the importance of Sequential Organ Failure Assessment (SOFA) in the risk assessment of sepsis patients, according to a recent White Paper on the topic from the ACDIS Advisory Board. And there continues to be conflict between clinical language, coding language, and the language required by quality assessment programs. (Read the related White Paper on the topic on the ACDIS website.)

But Haik, a founding member of the ACDIS Advisory Board, has a knack for breaking complicated clinical and coding conditions into manageable pieces of information, providing concrete examples of what clinical indicators CDI specialists should look for in the medical record and how to best craft a query to convey the patient’s condition in codeable terminology. Just as he has a knack for a quick comeback and rich and hearty laughter.

“We arm wrestle during my talk,” he says. “Just kidding,” he adds. “In reality, I’m trying to get participants to think inside the box! I want to get everyone to think clinically as a physician would.”

Striking a serious tone, he adds that presentations on quality, hierarchical condition categories, and value-based purchasing represent topics of interest. “I’m really looking forward to expanding my knowledge,” he says.

He’s not alone. The 10th annual conference features many physician presentations including that of Ronald Hirsch, MD, vice president of the regulations and education group at AccretivePAS Clinical Solutions, who presents on Day 2, Track 4, 11:15 a.m. to 12:15 p.m.

Hirsch knows how CMS’ regulations and guidance can confuse even the most astute clinician with its vague and often contradictory instructions. Nevertheless, these regulations affect everyone—doctor, patient, bedside nurse, case manager, CDI, billing and coding, even healthcare executives.

While his presentation “Medicare Regulation Update: Practical Application for CDI Professionals” promises to shed a light on this often opaque information, Hirsch is looking forward to learning just as much from his peers and other breakout sessions throughout the conference.

2016 pre-cons

2016 pre-cons

“With the breadth of courses available at the conference, I expect to walk out with a much deeper understanding of CDI. I can’t wait for the pre-conference physician advisor Boot Camp. It will be an honor to hear from Erica Remer and James Kennedy, two of the most renowned physicians in CDI,” Hirsch says.

Fellow physician, Nicole Fox, MD, MPH, FACS, CPE, medical director of pediatric trauma and CDI at Cooper University Health Care in Camden, New Jersey “cannot wait to hear about other program’s successes,” she says.

Fox, who presents “Playing to Win: How to Engage Physicians in Clinical Documentation Improvement,” on Day 3, Track 3, from 11 a.m. to noon, says she’s particularly interested in ambulatory CDI as Cooper University plans for its next area of growth and expansion.

Just as Fox looks forward to hearing other people’s CDI success stories, she’s excited to share her own, too. “One of the strengths of our program is physician engagement,” she says. “Physicians are never taught how to document, so they struggle with this much-needed skill set and are often hesitant to ask for help.”

Cooper University’s CDI program, however, tracks a 100% response rate to its CDI department queries, a rate at least partially attributed to the peer-to-peer education Fox helped establish.

“I think one of the general challenges with physician engagement is not recognizing that the best way for physicians. There is no substitute for a practicing physician embedded in your CDI program who will proactively educate peers and handle any concerns that arise,” she says.

Cooper University also has a remote component to its CDI program. Past ACDIS Achievement Award winner Kara Masucci, RN, MSN, CCDS, and her manager Rebecca R. Willcutt, RN, BSN, CCS, CCDS who both work at Cooper University, join Boston Medical Center’s Lara M. Faustino, RN, BSN, CCDS for a panel discussion on Day 2, Track 2, at 9:15-10:15 a.m., for a panel discussion on remote CDI efforts.

General session networking

General session networking

Like Fox, Faustino’s looking forward to learning from industry experts and peers and, of course, “networking! I always enjoy learning from a variety of CDI professionals from across the nation and it always amazes me how very similar we are, or how vastly different we approach the same types of challenges.”

When Jeff Morris, RN, BSN, CCDS, now CDI supervisor at University of South Alabama Health System in Mobile, first started in the role it was as a liaison between coding and physician staff to provide documentation education related to ICD-10 specificity. With numerous ICD-10 delays, however, Morris transformed the program, added staff, and expanded into focus areas such as CDI in obstetrics and gynecology, which he’ll explore on Day 1, Track 5, at 3:45 p.m.

“I am most looking forward to the networking and collaboration that occurs between CDI professionals during these few days. I always leave the conference refreshed and full of new ideas to bring back and implement at my facility,” Morris says.

There’s a lot to get excited about this year, especially with the 10th anniversary festivities. What sessions are you looking forward to most? What’s your favorite part of the ACDIS conference every year?


Lunchtime catch-ups

Note from the Associate Editorial Director: CDI Journal focuses on quality

by Melissa Varnavas

Healthcare has often been referred to a both a science and an art. Nevertheless, the healthcare industry continues its hunt for proof of quality healthcare services to, as much as possible, remove the art portion of the art-versus-science debate. That’s why the March/April edition of the CDI Journal pulls from a range of experiences and expertise to examine the many ways CDI efforts touch quality measures.

As Congress continues working to dismantle the Affordable Care Act (ACA), a wide range of vested entities contemplate the future of government payment methods. Hospital value-based purchasing (VBP), part of the ACA, offers a number of incentives—both positive and negative—to more closely tie patient outcomes to reimbursement on a host of measures. VBP represents the most comprehensive government pay-for-performance program, but it’s easy to feel overwhelmed by its various components when also considering the myriad collections of quality-focused programs hospitals and physicians need to navigate.

Quality-tied payments and public reporting measures can seem like the multi-headed Hydra of Greek lore—no sooner has a CDI program focused on, and defeated, one serpent than two other initiatives pop into existence. CDI programs understand the need to expand record review efforts, now that CC/MCC capture isn’t their only documentation goal.

Cheryl Ericson, MS, RN, CCDS, CDIP, does a nice job of summarizing the shift in her “Note from the Advisory Board” on p. 6, and on p. 10, ACDIS Editor Linnea Archibald looks at the various components of CMS’ VBP efforts, including a review of hospital-acquired conditions and present on admissions indicators. These articles help illustrate the complexity of quality concerns.

These aren’t the only measures considered in this issue, either. Advisory Board member Sam Antonios, MD, FACP, SFHM, CCDS, offers three tips for programs to help improve outcomes in regard to readmission reductions on p. 8, and ACDIS member Bonnet Tyndall, RN, CCDS, provides readers with a case study of how her team implemented record reviews for mortalities on p. 19.

All these potential review targets can be daunting, but don’t be intimidated. Take a look through this edition of CDI Journal and note how many of these programs aim to capture some of the diagnoses already found on most CDI programs’ top 10 lists.

As ACDIS CDI Boot Camp instructor Allen Frady, RN, CCDS, CCS, says on p. 22, “times like these are exciting for us CDI nerds.”

Editor’s Note: Varnavas is the Associate Editorial Director for ACDIS, overseeing its various publications and website content. Contact her at

Conference Conversations: Fox helps make CDI programs “physician-friendly”

Fox, Nicole

Nicole Fox, MD, MPH, FACS, CPE

Editor’s Note: The ACDIS Conference is only a little over two months away. Over the coming weeks, we’ll take some time to introduce members to a few of this year’s speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we talked to Nicole Fox, MD, MPH, FACS, CPE, the medical director of pediatric trauma and CDI at Cooper University Health Care in Camden, New Jersey, who will be presenting “Playing to Win: How to Engage Physicians in Clinical Documentation Improvement.” Currently, Fox leads a team of 13 CDI specialists and achieved a 100% physician response rate to queries.

Q: What has been the biggest challenge you faced with physician engagement at your facility?

A: Actually one of the strengths of our program is physician engagement. We have a 100% response rate to our CDI queries. I think one of the general challenges with physician engagement is not recognizing that the best way for physicians to receive information is peer-to-peer. There is no substitute for a practicing physician embedded in your CDI program who will proactively educate peers and handle any concerns that arise. Physicians are never taught how to document, so they struggle with this much-needed skill set and are often hesitant to ask for help. But, they respond most effectively to one of their peers.

Q:  What are three things attendees can expect from your session?

A: Attendees can expect an interactive, dynamic presentation. They will have tangible “take-aways” to help make their CDI program physician friendly. They also will have tools to handle difficult physicians.

Q:  What one tool can CDI professionals not live without?

A: An engaged medical director for their program.

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: This session challenges non-physicians to see CDI from a physician’s perspective and really evaluate their own program to determine whether or not they are set up for success in terms of physician engagement.

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

A: I cannot wait to hear about other program’s successes, particularly with ambulatory CDI which is our next area of growth and expansion.

Q: Fun question: what’s your favorite breakfast food?

A: An egg white burrito with quinoa and black beans. It’s awesome with tomatillo sauce. They make a great one at the Wynn Hotel café in Vegas, so try one while you are out at the ACDIS conference.


Guest Post: Discharge summary critical to hospital data quality and pay-for-performance, part 3

Time to take action

With the help of our hospital quality improvement (QI) committees, we can take action to restore the integrity of the discharge summary. Consider the following:

  • Advocate timely completion of the discharge summary and overall chart, preferably within a week of the patient’s discharge. The Medicare Conditions of Participation require that the entire medical record be completed (i.e., signed, sealed, and delivered) within 30 days of inpatient discharge; some states, such as California, have stricter deadlines. Summaries must be performed within seven to 10 days if they are to be typed and signed prior to the 30-day deadline. Even with these generous deadlines, good patient care requires that we do our summaries as soon as possible.
  • Insist that discharge summaries meet quality standards. Have the QI committee audit physician discharge summaries for at-risk conditions, such as pneumonia, myocardial infarction, and heart failure. Involve the coding manager or clinical documentation specialist to learn how the terminology used affects resource intensity or risk of mortality determinations. Follow up with a corrective action plan when deficiencies are found.

Thank you again for the efforts you take to ensure data quality. Please let me know of other topics you would like me to address in this column.

Editor’s note: This is the third part in a three-part series. To read the previous two sections, click here and here. Kennedy is the president of CDIMD-Physician Champions in Nashville, Tennessee. This article was originally published in the Revenue Cycle Advisor. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board. 


Guest Post: Discharge summary critical to hospital data quality and pay-for-performance, part 2

James S. Kennedy

James S. Kennedy

The third reason that the discharge summary is more important than the H&P is that, given that the ICD-10-CM principal diagnosis establishes the foundation for the diagnosis-related group (DRG) essential to cost-efficiency measurement, we must be crystal clear what condition we determined (after study) to be the reason for which we wrote the inpatient order, how the diagnostic approach or treatment evolved, why the patient had an unexpectedly long length of stay, or why he or she consumed additional resources. If two or more reasons qualify, coders can pick a higher-weighted code if it is supported by the documentation. For more information on principal diagnosis selection, read this related article.

For example, a woman presents with pancreatitis, and the diagnostic workup determines that it is due to gallstones. In MS-DRGs, if the ICD-10-CM code for gallstones is sequenced as the principal diagnosis instead of the ICD-10-CM code for acute pancreatitis, almost double the resources are allocated to that admission. The coder, however, may not choose the gallstones as the principal diagnosis unless the discharge summary shows, beyond a shadow of a doubt, that the circumstances of admission, the diagnostic approach, and the treatment rendered support the gallstones as the principal diagnosis. This may require that we overtly document how the admission was not only to treat the patient’s acute pancreatitis, but also to determine its underlying cause. Under most circumstances, a cholecystectomy would be performed during that hospitalization; however, if the surgery is delayed, an overt discussion on the reason for the delay can help a coder understand why the gallstones could still qualify as a principal diagnosis, even without surgical treatment.

We have the same situation with atrial fibrillation and decompensated systolic or diastolic heart failure. Atrial fibrillation as a principal diagnosis is higher-weighted than heart failure when they coexist. Unless we discuss how the patient’s atrial fibrillation contributed to the patient’s decompensation and demonstrate that it influenced the diagnostic approach and treatment rendered (assuming it did), the coder may be less secure in sequencing atrial fibrillation as a principal diagnosis, however.

Last, but not least, the discharge summary is the only part of the inpatient medical record in which we may document uncertain, probable, likely, suspected, or still-to-be-ruled-out diagnoses, and from which a coder may code those diagnoses as though they existed. Physicians and coders cannot apply this rule on outpatient facility or physician claims. It is only allowed for inpatient facilities. Not only does this affect DRGs, it also factors into the hierarchical condition categories (HCC), and affects our cost efficiency under value-based purchasing and other CMS initiatives.

For example, the physician admits a due to chest pain. After a diagnostic workup, the physician determines the pain is noncardiac and discharges the patient home on a proton pump inhibitor. The DRGs for noncardiac chest pain are lower-weighted than those for heartburn or gastroesophageal reflux disease. Unless we state in our discharge summary that the chest pain was likely due to these conditions necessitating the use of the proton pump inhibitor, the coder must use chest pain as a final diagnosis. It doesn’t help to only state these clinically valid possibilities in the H&P, progress note, or consultation report; someone must clearly cite them in the discharge summary if they are to be reported.

In another example, a patient is admitted with pneumonia whereby all diagnostic studies are negative. Based on the definitive antibiotics prescribed, what organism does the treating physician think likely caused the patient’s pneumonia? If the patient received a full course of vancomycin, might the physician think the pneumonia was due to MRSA? The coder cannot code this thought, however, unless the physician puts it in the discharge summary.

Most HIM professionals agree that physicians procrastinate completing their discharge summaries. Physicians often delegate the task to individuals who may not have the proper insight into the patient’s condition, such as medical students, house staff, or nurses. These summaries often lack underlying causes, complicating factors, and consequences that affect resource utilization and severity of illness. They may not resolve conflicting information provided by various consultants. The result is a subpar summary, which in turn leads to poor data quality.

Editor’s note: To read part 3 of this article, come back to the blog next week! Kennedy is the president of CDIMD-Physician Champions in Nashville, Tennessee. This article was originally published in the Revenue Cycle Advisor. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board. 


Book Excerpt: Review all charts to maintain a compliant CDI program

Trey La Charité, MD, FACP, SFHM, CCDS

Trey La Charité, MD, FACP, SFHM, CCDS

If at all possible, CDI programs should review all hospitalizations in a facility for documentation improvement opportunities. And all charts truly means every chart, including every insurance product, regardless of reimbursement mechanism (i.e., by MS-DRG or per diem), including the no-insurance and charity cases. The reason for this directive is multifaceted. First, reimbursement certainly is not the only purpose of a CDI program’s efforts. Even if a particular payer reimburses on a per-diem (per-day) basis or by a different DRG system (i.e., APR-DRGs), meaning there may not be any reimbursement benefits to improved documentation, CDI efforts still offer significant gains.

In particular, every payer employs some form of risk adjustment methodology to compare the outcomes of care between different providers. In other words, a facility’s providers look better to an insurer if they achieve the same results as a competing facility’s providers but do so caring for sicker patients.

Second, the need for a particular patient’s hospitalization must be justifiable. It doesn’t matter how many high-dollar diagnoses a CDI professional identified in the medical record if the payer – be it Medicare or private insurer – denies the claim. The sicker the patient is – both in fact and on paper – the harder it is for an auditor or a payer to justify that the patient should never have been admitted at all or that the patient should have been cared for in observation as opposed to being admitted as an inpatient.

If a CDI program is understaffed and simply does not have the resources to review all charts, program goals should evolve such that more than just the Medicare cases are reviewed. In other words, a CDI program should not be reviewing only Medicare patients.

If a CDI program reviews only Medicare cases, the government and the Office of Inspector General (OIG) believe that hospitals preferentially targets Uncle Sam’s coffers. Don’t increase your facility attractiveness to those who are looking for additional targets. By reviewing all payers, facilities set the precedent that increased reimbursement from CMS is not the only goal of a CDI program.

Editor’s note: This excerpt was taken from the CDI Field Guide to Denial Prevention and Audit Defense by Trey La Charité, MD, FACP, SFHM, CCDS.

Conference Conversations: Morris ventures into CDI for OB/GYN

14-Jeff Morris

Jeff Morris, RN, BSN, CCDS

Editor’s Note: Over the coming weeks, we’ll take some time to introduce members to a few of this year’s ACDIS conference speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we talked with Jeff Morris, RN, BSN, CCDS, the supervisor of clinical documentation improvement (CDI) at University of South Alabama Health System in Mobile, Alabama, who is presenting “CDI in Obstetrics and Gynecology: A Roadmap to Program Development and Success.” Morris has 20 years of nursing experience in adult critical care, medical-surgical/telemetry, and emergency department (ED). Morris was the first CDI specialist hired at USA Children’s and Women’s and now has five years of experience in CDI. He is an active member of ACDIS and is an Alabama ACDIS Chapter leader.

Q: Could you tell me a bit about the why your facility developed its CDI program?

A: Initially, our organization hired CDI specialists to be liaisons between our coding and provider staff to provide documentation education related to ICD-10 specificity. With numerous ICD-10 delays, we transformed from a non-traditional program to a traditional program and added additional staff members.

Q: What are three things attendees can expect from your session?

A: Let me give you a list:

  • Determine the need for CDI reviews of OB-GYN records at an individual facility and begin implementation of such a program
  • Become familiar with Official Guidelines for Coding and Reporting and AHA Coding Clinics specific to the OB-GYN patient population
  • Identify strategies for program success, program maintenance, and metrics to monitor

Q: What is one tool a CDI professional cannot live without?

A: The CDI Pocket Guide, it’s an invaluable resource that all CDI specialists should have.

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: I am happy to be co-presenting this session with Beverly Lambert, RN, BSN, our main CDI contact in the OB/GYN patient population at our organization. OB/GYN is a patient population most CDI programs do not review. There are many documentation nuances that are very specific to this patient population, but there are also commonalities.

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

A: I am most looking forward to the networking and collaboration that occurs between CDI professionals during these few days. I always leave the conference refreshed and full of new ideas to bring back and implement at my facility.

Q: Fun question: What is your favorite breakfast food?

A: French toast. We have a place in town that has awesome bananas foster French toast!