RSSAll Entries in the "Questions from the Mailbox" Category

Q&A: Hospital-acquired conditions versus hospital-acquired pneumonia

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Q: Why is hospital-acquired pneumonia not considered a CMS hospital-acquired condition (HAC)?

A: This is confusing to a lot of people because of the similarity of terms used. Hospital-acquired pneumonia is a clinical descriptor. However, CMS’ hospital-acquired conditions are more of a payment classification than a clinical classification. Thus, those conditions that are certainly hospital acquired from a clinical perspective may or may not be a CMS hospital-acquired condition.

Hospital-acquired conditions are conditions that CMS has classified as preventable, and thus are not subject to additional payment coverage. At this time, hospital-acquired pneumonia is not considered a HAC by CMS.

Here are some links for further reading:

I hope this helps!

Editor’s note: Allen Frady RN-BSN, CCDS, CCS, CDI Education Specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at For information regarding CDI Boot Camps visit

Q&A: Community-acquired pneumonia

Q: How do we determine if a patient’s pneumonia is community acquired or not? What documentation should we look for to support this?

A: To be honest, any type of pneumonia can be acquired in the community. However, physicians often use the term “community acquired” to signify a simple pneumonia. Simple pneumonia is usually easily treatable, although the term is somewhat self-limiting. The diagnosis causes unique problems for CDI specialists.

In general, simple pneumonia cases would not and should not be admitted to the hospital for inpatient status. They could be admitted, however, if they have a number of other medical problems that further complicate the care of their pneumonia, or are becoming acute themselves—for example, a congestive heart failure (CHF) patient getting fluid overloaded, a diabetes patient with an out-of-control blood sugar level, or a very elderly patient who also has a urinary infection and has now become confused.

We certainly would not want to make a blanket statement that any patient admitted to the hospital probably has a gram-negative or complex pneumonia. But, oftentimes, the pneumonia by itself does not support the admission.

“Atypical” is a term used by physicians to describe a unique presentation of pneumonia that has its own set of chest x-ray findings, history, and treatment requirements. Generally, atypical pneumonia is usually caused by one of the organisms classified as a complex pneumonia for DRG assignment purposes. Unfortunately, the term “atypical” codes to one of the simple pneumonia types.

Interestingly enough, “hospital acquired” and “healthcare acquired” are almost always written when the physician is attempting to describe a more complex pneumonia, resistant to treatment, in a patient who has a higher acuity illness. Unfortunately, these terms code to simple pneumonia classifications, too. Physicians are almost always surprised (and often disagree) with these phrases being classified as “simple.”

For this reason, what I teach CDI specialists to ask for the specific organism, and to either document that organism as either confirmed or suspected at discharge. Getting the exact organism is not always possible. Nevertheless, physicians need to document their assessment based on the same clinical evidence that caused them to treat that patient in one manner versus another.

For CDI specialists, the moral here is that when physicians document “atypical,” “hospital-acquired,” and “healthcare-acquired” you may need to craft a query, so providers don’t get an inappropriate downgrade.

Furthermore, CDI specialists may need to query the physician regarding patients sick enough to be admitted to the hospital for community-acquired pneumonia, particularly if the physician did not include any additional documentation regarding comorbidities. It may be that the patient actually has sepsis, or reveal a more specific causative organism which changes the classification to a more complex pneumonia.

Worst case scenario, a reassessment of the utilization procedures may need to occur if a large population of simple pneumonias is actually being admitted with no complications, no co-morbidities, no risk factors, and they genuinely do have simple gram positive type pneumonias.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI Education Specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at For information regarding CDI Boot Camps visit

Q&A: Morbid obesity

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Have a question that is troubling you and your team? Ask us!

Q: Coding Clinic, Third Quarter 2011, p. 4 states:

“…morbid obesity is a chronic condition and; therefore, can be coded as a secondary diagnosis without treatment.” (emphasis added)

An article in the CDI Journal, “From the Forum: Manage denials for BMI morbid obesity,” seems to indicate that providers should document how the obesity affects patient care.

What level of patient care needs to be documented?

A: The Coding Clinic you are referring to states:


If the provider documents obesity or morbid obesity in the history and physical and/or discharge summary only without any additional documentation to support clinical significance of this condition, can it be coded? There is no other documentation to support clinical significance such as evaluation, treatment, increased monitoring, or increased nursing care, etc., for this condition.


Individuals who are overweight, obese or morbidly obese are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore, these conditions are always clinically significant and reportable when documented by the provider. In addition, the body mass index (BMI) code meets the requirement for clinical significance when obesity is documented. Refer to Coding Clinic, Third Quarter 2007, pages 13-14, for additional information on coding chronic conditions.

Coding Clinic clearly states that morbid obesity should be coded when it is documented by the provider. It speaks to the fact this condition is always clinically significant. That said, morbid obesity is almost always addressed by both the provider and the nursing staff caring for the patient. These patients are more prone for infections, musculoskeletal injury, skin breakdown, respiratory compromise, etc., and, therefore, the medical decision making and care for this patient will be more complicated. This is why we are able to code this diagnosis whenever it is documented by the provider.

After this Coding Clinic was released, I have not seen a denial for this diagnosis. If you feel you need to expand documentation related to the condition, ensure your nursing plans reflect care of a morbidly obese patient. Your provider should also include their concerns related to the condition in their assessments.

Editor’s note: Laurie Prescott, RN, MSN, CCDS, CDIP, CRC, answered this question. Prescott is the CDI Education Director at BLR Healthcare in Middleton, Massachusetts. Contact her at For information regarding CDI Boot Camps visit

Q&A: Query peer-auditing  

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Go ahead, ask us!

Q: Is it written in ACDIS Code of Ethics that, as CDI specialists, we are to “pull” bad or non-credible queries from patient charts and report them to our manager? This is what I have been taught in my current position.

A: As a manager, I would never ask my staff to be confrontational with each other. Queries should be audited on a regular basis—the manager or designee should regularly perform random audits of queries to ensure they are written compliantly and are appropriately assigned (no queries for unwarranted reasons), as well as identifying missed query opportunities.

Many departments also conduct peer reviews where each CDI specialist performs a selected audit of coworkers reviews and queries against facility and industry standards (such as the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice). The group then discuss their findings and exchange ideas about what may have been missed or how a given query may have been more effectively worded.

I would never ask a CDI specialist to pull a query by another coworker like that. If they found something terribly concerning, it should be reported to the manager, and the manager can determine if the query should be pulled, etc.

This example, in my opinion, is not related to CDI ethics as much as it is management and leadership. Every program should have an established method of query audit.

Editor’s note: Laurie Prescott, RN, MSN, CCDS, CDIP, answered this question. Prescott is the CDI Education Director at BLR Healthcare in Middleton, Massachusetts. Contact her at For information regarding CDI Boot Camps visit

Q&A: Compliant queries  

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Got a question? Ask us!

Q: I have a question about the following query. If the response is B, can you still capture it as withdrawal?

Based on these indicators taken from the medical record, please clarify by documenting on this query form and/or in the progress note the condition being treated with a nicotine patch and nicotine gum in this patient referred to as a “smoker” in the history and physical documentation.

  1. Nicotine/tobacco withdrawal
  2. Prophylactic treatment of nicotine/tobacco withdrawal
  3. Unable to determine
  4. Other (please specify)

A: I like your query but, unfortunately, when treating something prophylactically, by definition we are preventing it from occurring. A condition that is being prophylactically treated should not be coded.

According to the 2016 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice brief, we only need to provide “reasonable options” in a query. “Reasonable options” are determined based on the clinical indicators present in the medical record and, sometimes, there is only one appropriate response based on the clinical indicators present.

We want the documentation to accurately reflect the true picture of what is going on with the patient during the episode of care that is under review, so if the patient is not experiencing withdrawals, and is only being treated prophylactically to prevent the withdrawals, that is what we want the documentation to reflect.

Here are some sample queries for this scenario:

Documentation indicates a 25-year history of smoking cigarettes. Patient admitted to unit after six hours in the ED. Nursing notes describe increased irritability and continued requests to be allowed to smoke. Vital signs indicate elevated heart rate and blood pressure readings as described by nursing notes. Upon admission telephone order obtained for nicotine patch. Please clarify the indication for nicotine patch.

  1. Nicotine/tobacco withdrawal
  2. Prophylactic treatment of nicotine/tobacco withdrawal
  3. Unable to determine
  4. Other (please specify)

You have ordered the application of a nicotine patch for this patient with a history of smoking cigarettes for 10 years. The H&P indicates a “habit of 2.5 packs a day”.  Nursing documentation in the ED and admitting unit describe the patient exhibiting anger and threatened discharge against medical advice. Nicotine patch applied 2 hours after admission. Later nursing notes indicate the patient is presenting in much calmer manner and cooperative with plan of care. Please clarify the condition you are treating with the application of the nicotine patch.

  1. Nicotine/tobacco withdrawal
  2. Prophylactic treatment of nicotine/tobacco withdrawal
  3. Unable to determine
  4. Other (please specify)

Editor’s note: Sharme Brodie, RN, CCDS answered this question. Brodie is a CDI education specialist for ACDIS and HCPro in Middleton, Massachusetts. Contact her at For information regarding CDI Boot Camps offered by HCPro, visit


Q&A: Technology

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As part of the sixth annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Joy Coletti, MBA, RN, CCDS, system services director for clinical documentation improvement at Memorial Hermann in Houston, Texas, answered these questions on electronic health records. Contact her at

Q: How long has your facility been using electronic health records? 

A: It was phased in at each hospital over a one to two-year timeframe in early 2000. Two of our smaller community hospitals took the lead with engaged physician champions.

Q: What role did you personally play in the transition? How big a role did the CDI team play?

A: CDI did not really play a role in initial EMR adoption, unfortunately, other than [providing input on] how physicians are electronically prompted when they have a query, and where those query responses reside in the EHR.

Q: What was the impetus for the transition initially (ICD-10? Government imitative?)?   

A: HIPAA was likely a large factor in speeding up the transition. E-queries were implemented in 2010. By 2010 the EMR was more electronic than paper, but still a hybrid of the two.

Q: Can you describe the different systems you use for your EHR and e-Queries? 

A: EHR is a Cerner platform, but also has Intelligent Medical Objects which allows us to search diagnoses. For e-queries, CDI specialist and coders software were developed by Meta Health, now part of Streamline Health.

Q: Has EHR use led to remote CDI capabilities?  

A: Yes, but within each hospital. Records are reviewed from an office location rather than within the units. This has significantly improved productivity levels. Records can also be reviewed across hospitals for coverage capabilities when a CDI specialist is out of the office or when census is very high at certain facilities. I hired three regional float CDI specialists who support multiple hospitals remotely from their offices on one hospital campus. Each CDI float supports multiple facilities and provided backup coverage.

Q: What has been the biggest benefit from EHR implementation in your opinion? 

A: Legibility of documentation, the ability for many disciplines to access the record simultaneously, remote access, and quicker order entry with fewer errors.

Q: What has the CDI team struggled with most in terms of reviewing records in the EHR and helping physicians with their documentation?

A: First, fragmentation of the EHR, which makes it challenging for physicians to “tell the patient’s full story” in an accurate and efficient manner. Providers sometimes produce a lot of copy-and-paste generated notes, which are challenging for CDI specialists and coders to follow and understand the patient’s story.

Second, there are no central diagnosis or problem lists managed by physicians that can be used by CDI specialists and coders.

Q: What advice would you give to CDI specialists who might be just starting EHR implementation or struggling through the process?

A: Continue to use paper queries until the EHR is at least 50% electronic, or at least a majority of history and physicals and progress notes are electronic. Once you transition to e-queries, while the health record is still hybrid, place a paper query “prompter” in the paper record to alert providers they have an electronic query, the basic steps for how to answer that e-query, and, of course, the CDI specialist’s name and contact information.

Q: What contingency plans are in place for when the power goes out or internet goes down? (you can skip this question if you want, I’m just curious in light of the flooding in LA and the fires in CA and knowing what happened in NYC after Sandy.)

A: Luckily, our back-up generators have always kicked in. All generators were moved out of basement level years ago due to the history of flooding in Houston area. Our IT emergency plans kick in when the EHR goes down and “all hands on deck” until the issue is identified and the EHR is back up and running. In the past, we were able to be back up within two hours.

Q&A: Interdepartmental collaboration

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As part of the sixth annual Clinical Documentation Improvement Week, ACDIS has conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Susan Lapp, RN, MSW, a clinical documentation improvement specialist for Community Hospital, South, in Indianapolis, Indiana.answered these questions about interdepartmental collaboration.

Q: How often to get to collaborate with the coding team?

A: We’re a hospital-based network of several facilities, each facility has a CDI staff member. If someone is off, we can cover. We report up through case management and help with length of stay needs.

We each work as a team with a remote coder. We get used to each other’s work habits and patterns. We use a program called “Jabber” that allows us to share each other’s computer screens and chat. We meet once a month with all the coders and all the CDI specialists for group discussion and education. The CDI team also meets once a month.

We have an escalation policy that we can use if the coder and the CDI specialist disagree on an issue. The case gets bumped up to our managers and they get the final say. It’s a good process that allows us to not take it personally and lean on someone else with more experience for a determination.

Q: What type of other groups do you work with?

A: Our physician advisor was working on denials and identified malnutrition as a frequent cause of denials. So we reached out to dietitian and started working on guidelines for documentation. Once we had that in place we were able to go out and provide physician education.

Within the case management team, we spend a lot of time discussing what the principal diagnosis of the case should be. Sometimes what needs to be the principal diagnosis isn’t the diagnosis with the longest length of stay but that’s what the coding rules call for.

A couple months ago, there was a case (case description altered to protect HIPAA requirements) where an elderly gentleman wasn’t correctly taking his medication. He came in once for an overdose and was discharged and when he came back again for a similar situation shortly thereafter, I was able to get the case management team together to re-evaluate their discharge plans.

We disagreed about what the documentation seemed to indicate, so we brought the treating physician in and determined that the patient indeed wasn’t able to self-monitor the medications any more. They found placement for him and his elderly wife. I think this is a perfect example of what a positive effect we can have when we collaborate.

Q: Are you doing any work with other departments on quality measures or that type of reviews?

A: We automatically get notified if the same patient comes back within the 30-day window, so we review those records and identify any clarification opportunities. This helps with NSTEMI documentation and with quality.

We also always look to see if the condition is present on admission or if it’s a hospital acquired condition. If we’re not sure we query the physician.

Complications are another area related to quality that we look at. I don’t know why they can’t just write whether it’s an expected outcome or not. I’ve been in nursing for 39 years and I never thought they’d pay me for this type of work but it’s great. I want my patients to have the best treatment possible and I help the record reflect that.

Q: What advice do you have for others who may be wishing they could collaborate a bit closer with other departments?

A: Be comfortable with the resources you have and be willing to ask questions. I’m not a coder, I’m a nurse. I don’t know what my coders know, that’s why they’re coders. You have to know your limitations as well as your expertise. There might be a difference in opinion as to how you interpret two little words but that difference might mean a patient gets sent home when they really shouldn’t be.


Q&A: Coronary stent

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Go ahead, ask us!

Q: The 2016 CDI Pocket Guide states that four or more stents or vessels is equivalent to an MCC and changes the DRG. I understand that Coding Clinic, Second Quarter 2015 defines the number of individual sites instead rather than anatomical vessels. The DRG Expert states four vessels or four plus stents changes the DRG. It was my understanding that when four stents are used in three vessels or sites, the DRG would not change. Could you please clarify if it is the number of stents or the number of sites that changes the DRG?

A: The coronary stent question has plagued the entire coding and CDI community since Oct. 1, 2015. There is much self-contradiction in the DRG titles, which includes vessels and stents, and the meaning of “sites” (implying stent locations) in the ICD-10-PCS Official Guidelines for Coding and Reporting. The Coding Clinic advice published in Second Quarter 2015 helped some, and I believe intended to clarify that the number of coronary arteries treated determines the code assigned, which then drives the DRG.

Because of the confusion and contradictions, the 2017 ICD-10-PCS Official Guidelines for Coding and Reporting sections B3.6, B3.7, B4.4 have been modified to indicate that procedures performed on coronary arteries are classified by the number of arteries treated, not the number of coronary artery sites.  The number of stents does impact code assignment or DRG classification, but the code titles for DRGs 246 and 248 still perplexingly retain “4+ vessels/stents.”

Editor’s note: Richard D. Pinson, MD, FACP, CCS, principal of Pinson & Tang LLC, and author of the CDI Pocket Guide answered this question. Contact him at

Q&A: Procedure code for esophagogastroduodenoscopy

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Got a question? Ask us!

Q: What is the correct procedure code for an esophagogastroduodenoscopy with placement of clips to control bleeding? Our coder coded 0DQ68ZZ, which groups to DRG 326, the same as an esophagectomy. The relative weight (RW) is 5.45. This does not seem right. Could you please clarify?

A: This was addressed in AHA Coding Clinic for ICD-9-CM, Fourth Quarter, 2014. The coder is correct in their assignment. The only difference is that this was in the esophagus, but the intent is the same. I am assuming it is because the clips act as a “suture” to stop the bleed, and therefore it is considered a “repair,” much like suturing for the integumentary system.

Coding Clinic states:


A patient presents with bleeding duodenal ulcer and an esophagogastroduodenoscopy was carried out. Multiple clips were applied to the vessels to control the multiple hemorrhaging ulcers. Should “control” be assigned for the root operation? What is the ap­propriate ICD-10-PCS procedure code?


The root operation “control” is defined as only applicable for procedures to correct postoperative bleeding, and so it does not apply to this procedure. This procedure is a repair of the duodenum. Most of the body’s organs and tissues are vascular, and they bleed when cut or eroded. Repair of a cut or eroded body part is coded to the body part repaired, rather than to a vascular system body part. In this case, the duodenal ulcers are being repaired via an endoscop­ic approach, with clips placed on vessels eroded by the ulcers. Assign the following ICD-10-PCS code: 0DQ98ZZ Repair duodenum, via natural or artificial opening endoscopic.

I think why this seems so problematic is that in ICD-9-CM, the code would likely be 42.33, endoscopic excision or destruction of lesion or tissue of esophagus, which includes control of esophageal bleeding and was considered a non-operating room procedure. The ICD-9-CM code was very generic. When translating to an ICD-10 code, the intent of the procedure seems to have been taken into consideration. This procedure is the same intent as suturing sites like the duodenum and stomach for bleeding, which was assigned to a surgical DRG. This would be my guess as to why it maps to DRG 326, though I agree that the RW seems very high.

Editor’s note: Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS Director of HIM/Coding for HCPro in Middleton, Massachusetts answered this question. Contact her at For information regarding CDI Boot Camps visit

Q&A: SOI/ROM impact

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Have a question? Leave a comment below!

Q: I am with a CDI program that is starting to explore the severity of illness/risk of mortality (SOI/ROM). I personally have been reviewing for SOI/ROM for quite a while. I usually designate the impact (MCC/CC/SOI/ROM) after the billing is done and see if what I queried for made a final impact, and only take credit for those that do.

I was told that regardless of the actual final impact on SOI/ROM we should be taking credit for any SOI/ROM clarification as SOI/ROM impact. Which is the most accurate, “correct” way to capture the CDI impact for these types of clarifications?

A: I very much agree with your practice of claiming those in which you see a change in SOI/ROM related to your query. I believe you are being encouraged to claim impact for any query that allows for an increase in SOI/ROM. So, for example, if you query for MCC capture, that would likely affect SOI/ROM and I would claim the impact for both MCC capture and SOI.

Say you have a patient that is admitted for COPD exacerbation with heart failure and diabetes. When you query to capture the MCC of the acute respiratory failure, and the physician responds appropriately, you would claim the credit for the MCC capture. But this query likely would also increase your SOI/ROM (I do not have access to an APR grouper but my guess is that it likely would).

I would think that although your goal in the query was not to increase SOI/ROM, if it did indeed do so, I would take the credit for this as well.

I would also suggest you seek out your peers on the ACDIS Forum as they likely could share with you how they analyze their metrics.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at For information regarding CDI Boot Camps visit