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Next quarterly conference call to be held Thursday, August 27

The Association of Clinical Documentation Improvement Specialists (ACDIS) has announced the date of its next quarterly conference call: Thursday, August 27 from 1-2 p.m. ET.

As a reminder, these calls are offered as a means for ACDIS members to network with one another and to discuss any clinical documentation improvement related issues. We have a few ACDIS Advisory Board members on the calls as well to help spark discussions.

We encourage your comments, thoughts, and questions during these calls. Additionally, if you have any suggestions for discussion that you would like to forward along to our advisory board, please e-mail me at the address below.

ACDIS members will recieve e-mail instructions in advance of the call with dial-in instructions.


Brian Murphy, ACDIS Director

It takes a hospital. . .

A recent hospital audit of 300 medical records turned up some not too surprising facts about physicians. The doctors are still not documenting appropriately, their handwriting is illegible, and the discharge summaries are inadequate.

Recent changes in CMS regulations have made certain wording and diagnosis linking imperative for hospital coding and reimbursement. The new rules are confusing and complicated. Certain words need modifiers, certain diagnosis must be linked to their causative agents, other conditions must be rated as acute, exacerbated, or unstable.

Old dogs need to learn new tricks.

Old dogs need to learn new tricks.

There is an old expression that “You can’t teach an old dog new tricks.” I am starting to wonder if this shouldn’t also include physicians. I work in the Clinical Documentation Improvement office and we strive to educate physicians on the nuances of clinical documentation. This recent  audit indicates that we still have a lot of work to do.

I attended parochial school my entire life and I spent most of my formative years having to stay after school for poor penmanship. I still have terrible handwriting and I missed out on a lot of fun. This only goes to explain why I cannot criticize someone for having poor handwriting. The new computer era is upon us and with the advent of electronic medical records it also may be a mute point. I do not give penmanship classes.

However, like that old dog, the problem may be that seasoned physicians are too old to learn new techniques for documenting patient care. Perhaps we need to start educating the physicians sooner, when they are still in medical school.

The problem may be the lack of incentive. Perhaps the physicians need some sort of pay for performance to entice them to change their old habits.

Or the problem may be that hospitals need more upper management support for their CDI departments. Perhaps a series of speeches given by the CEO would get everyone motivated.

The problem may be a lack of educational resources. Perhaps hospitals should invest in teaching tools and educational literature.

The problem may be everything mentioned above and then some.

Clinical documentation teams across the country are working diligently to educate physicians and improve documentation. Blaming the CDI department for the deficiencies of the physicians, will not correct the problem. Secretary of State Hilary Clinton said “it takes a village to raise a child,” cribbing from an old African proverb. Well, maybe it takes a hospital to educate a physician.

Tip: Query for Noncompliance with medical treatment (V15.81)

CDI specialists should be on the lookout for indications of patient noncompliance with medical treatment when reviewing patients’ charts, says Garri Garrison, RN, CPUR, CPC, CMC, director of consulting services with 3M Health Information Systems (HIS) and a member of the ACDIS advisory board.

According to Garrison, payers are increasingly denying hospital readmissions and the problem is likely to worsen with the nationwide rollout of the Recovery Audit Contractor (RAC) program and CMS’ increasing scrutiny of the cost of readmissions. “Readmissions can be the result of, or influenced by, patients who leave the hospital and refuse or elect not to follow recommended treatment plans (by choice, by misunderstanding of discharge instructions, or due to costs), which may cause their condition to worsen, resulting in a readmission,” Garrison says.

However, CDI specialists can assist facilities by identifying when noncompliance plays a role in the readmission. By securing the necessary documentation to allow coders to report V15.81, hospitals can use this documentation and coded data to help prevent or appeal denials, Garrison says. “If the V code is reported in the top nine diagnosis codes when it is transmitted on the UB-04, (it allows) the payer to have the knowledge that patient noncompliance may have contributed to the readmission,” she says.

“I have always recommend the use of the V15.81 code for noncompliance to both coders and physicians when supported by the clinical documentation,” adds Gloryanne Bryant, RHIA, CCS, CCDS, regional managing HIM director, NCAL Revenue Cycle of Kaiser Foundation Health Plan Inc. and Hospitals in Oakland, CA, and a member of the ACDIS advisory board. “I agree this is helpful, but mostly for understanding which patients really are not following medical instructions. Is it the diabetic patient or the dialysis patient, etc?

“It further explains and provides insight into healthcare resource use, length of stay, costs, and readmission rates,” Bryant adds. “I would recommend that facilities run a data report on their inpatients with this V code assigned and conduct some audits and reviews to gather insight. I would also track/trend this V code over time and share the information with providers.”

CDI and the importance of real-time physician education

(Note: Glenn Krauss shared the following case study with me during a recent medical record review he conducted. I thought it would be interesting to share the case with members of ACDIS. Feel free to post your comments here.–Brian)


Although query forms and electronic prompts are invaluable tools in every CDI specialists’ toolkit, Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI, CCDS, an independent consultant in Janesville, WI, says that they shouldn’t serve as a substitute for face-to-face interactions with physicians. The following clinical scenario demonstrates why.


A patient is admitted to the hospital in hypertensive emergency (blood pressure of 210/130). The patient had previously controlled her high blood pressure with medication which she recently stopped taking. She receives IV Cardizem to lower her blood pressure. The ED physician documents that the patient presented with a severe headache and focal neurological deficits on her right-hand side, including facial droop and difficulty moving her right arm. The clinical impression in the ER is “likely CVA.”


The patient’s focal neurological deficits subside and resolve within the first six hours of the hospitalization, leading the physician to document TIA in the progress notes beginning on day two of the hospital stay. Of note (also on day two), the nurses observe and report to the physician that the patient is exhibiting an altered mental status with some confusion. The physician orders a urinalysis with C&S that shows > 100,000 CFU positive for E.Coli organism. IV antibiotics are started and patient’s fever and altered mental status begin to improve. However, on day three the patient’s altered mental status and confusion begin to worsen and a neurology consult is called.


The consulting neurologist performs an evaluation and documents that the patient’s neurological deficits are related to hypertensive encephalopathy, with no mention of stroke or TIA.


The attending physician, thinking that the patient may have viral meningitis due to continued headache, stiff neck, and waxing and waning mental status with confusion, begins the patient on Acyclovir therapy for herpes simplex virus infection. The patient is eventually discharged on the eighth day, with the following final diagnoses documented in the discharge summary:

  • “TIA with diffusion weighted MRI evidence of territorial infarct in the front lobe.”
  • Hypertension uncontrolled
  • Remote history of smoking
  • Hypercholesteremia
  • Obesity
  • Previous history of stroke

“In this instance the CDI specialist assumed that the physician’s impression was that of TIA with hypertensive encephalopathy, given the hypertensive emergency condition the patient presented with to the ER,” Krauss says. “Unfortunately, this was an ill-conceived assumption, given the results of the discharge summary.”


Krauss also notes that the physician’s documentation of etiologies for the patient’s clinical presentation does not do justice to the actual patient acuity nor the length of stay of the patient, particularly since the patient’s signs and symptoms align with more than one of the patient’s documented clinical entities, in conjunction with the documentation of TIA in the discharge summary,


Krauss notes that a coder is precluded from assigning anything other than TIA as the principal diagnosis in this case based upon the medical record documentation. Mention of a territorial infarct in the discharge summary appears to be described as a radiological finding versus a more definitive clinical disease process, he says of the case. 


The coder in this instance left a written query for the physician. Much to the despair of the coder, the physician answered the query as follows: ‘Your guess is as good as mine.’ 


Krauss says a better option for resolving this case is for the CDI specialist to engage in a clinical discussion with the attending physician, preferably concurrently or retrospectively if necessary. “We focus so much on leaving queries that we forget about the two-minute conversation,” he says. “This is a good place to educate the physician on the importance of documenting his or her practice of medicine and a good teaching moment.”


Explain to the physician that the diagnosis of TIA does not do justice to the acuity in his medical decision-making, suggests Krauss. “He didn’t mention anything about the herpes simplex virus, meningitis, or the fact that the TIA may constitute a stroke.” For a good reference, Krauss recommends sharing the American Heart Association/American Stroke Association scientific statement paper, “Definition and Evaluation of Transient Ischemic Attack,” available here:


The paper states that the arbitrary time threshold of 24 hours may be too broad, given that many studies have shown 30% to 50% of classically defined TIA’s show brain injury on a diffusion-weighted MRI. “In fact, the article goes on to point out also that some groups have advocated for the following definition of TIA: “a brief episode of neurological dysfunction caused by focal brain or retinal ischemia, with typical symptoms lasting less than one hour, and without evidence of acute infarction,” Krauss says.


In addition to the newly proposed definition of TIA vs stroke, this case reinforces the opportunity for the CDI specialist to incorporate the concepts of risk of morbidity and 30-day mortality, risk adjustment of potential for 30 and 90 day readmissions, measurement of physician efficiency in the delivery of healthcare, and the MedPac Commission’s proposal for Accountable Care Organizations as a strategy to slow the growth of Medicare expenditures.


“CDI specialists can capitalize upon the opportunity to bring relevant business developments in healthcare that directly impact the physician’s business of the practice of medicine from an operational and financial standpoint,” Krauss says.

St. Francis Hospital to start up local ACDIS chapter in New York

800px-statue_of_liberty2c_nyAdelaide M. La Rosa, RN, director of the Clinical Documentation Improvement Program for St. Francis Hospital in Roslyn, NY is passionate about CDI—and wants to share her expertise and ideas with other local programs. She is planning to start up a NY chapter of ACDIS (Long Island area) and is targeting September for the first meeting.

“We want to help the hospitals who don’t have the experienced leadership or funds to set up a program,” La Rosa says. “Small programs with one or two specialists can succeed.”

St. Francis began laying the groundwork for a CDI program about four years ago. The program went into full operation on October 1, 2007, and has experienced tremendous growth and success. “The care was there, but it was not being documented,” La Rosa explains. “I don’t speak about revenue with the physicians, but if documentation is accurate, it will come.”

Although St. Francis is known for specializing in heart procedures, Adelaide says that it has a diverse mix of patients and covers a wide variety of the Major Diagnostic Categories. In addition to providing high volume PTCAs, open heart surgeries, and treating CHF patients, St. Francis provides GI services, major GI procedures, oncology services, and hip and knee replacements, among other services.

If you are interested in participating in the upcoming kick -off meeting, e-mail La Rosa at:

The CCDS exam experience

“Only a life lived for others is worth living.” – Albert Einstein

Interesting that a man most known for his intelligence is quoted for his humanity and belief about sharing with others. With that thought in mind, I thought that I would share with the ACDIS membership my experience with test taking and the Certified Clinical Documentation Specialist (CCDS) exam so that others may benefit from my experience.

The most frequent question that I’ve had lately from other CDS’s once they’ve learned that I have taken the CCDS is exam is what I thought of the exam and what is the best way to prepare. I have been working with and training CDS’s for several years and the first word of advice that I can offer is to be confident that your knowledge base and experience gained from working in the role on a daily basis will serve as the best resource. Having a strong clinical background, knowing coding guidelines, understanding how to analyze the data and being able to communicate RAC purpose are areas that you should be confident in before you should consider taking the exam. However, like every other exam one takes as an adult, there is no true way to “study” for this exam. Instead, as a former nursing professor, I would like to offer some advice on test taking that might be helpful.

I made sure that I got a good night’s rest before the exam. Not easy to do in Vegas. Upon awakening the morning of the exam, I ate a protein rich but light breakfast and arrived at the test site early. I found my place, made a trip to the restroom and then spent a few moments relaxing and just getting comfortable in my assigned space. I find that this is key to staying relaxed and confident and doing well.

Once the test began, I made sure to read the directions carefully and listen to the instructions supplied by Brian Murphy. Although those of us who took the first exam in Vegas took a paper/pencil exam, I realize that most of you will take a computerized version. Probably the most important strategy to think about when taking a test by computer is time management. Do a quick calculation of how much time is allotted for the exam and divide by the number of questions on the test. This lets you know the average time that can be allotted for each test item. Keep your watch nearby but don’t look too often, stay focused to the questions and not the time remaining.

Ok, now the actual test taking. Read the question carefully, look for the central idea of each question. What is the main point? Eliminate those answers you know to be wrong, or are likely to be wrong, don’t seem to fit, or where two options are so similar as to be both incorrect. Once you decide on an answer don’t change it unless you made a mistake, or misread the question. Computerized tests do not usually allow you to easily go back and review answers. Since I’m a firm believer in the “gut-instinct” theory that works fine for me. Over analyzing questions usually leads to changing a correct answer to a wrong answer. So once you’ve read and completed a question move on! Never change your original answer unless you are sure it is completely wrong.

If you get panicked or frustrated, sit back, close your eyes and refocus. If necessary stand up and go to the restroom. To do well, you must remain calm, focused and comfortable. Don’t’ worry about the pace of others. Especially in a computer environment, most of the other test takers aren’t even taking the same exam. Therefore it is pointless to become concerned with the speed of the test takers around you.

So you’ve finished the exam, now what? Before reviewing results, it’s always important to take stock of the experience and learn from it. Jot down problem questions, thoughts, items you’d like to review or look up to clarify your knowledge. Pat yourself on the back! You’ve just completed an extensive exam and you deserve congratulations for having the strength to finish the exam. Regardless of how you’ve done, this was an exhausting experience and you are deserving of a small reward, hopefully a certificate to frame and hang in your office!

Preparation tips:

  • Arrive early
  • Be comfortable but alert
  • Stay relaxed and confident

During the test:

  • Make sure to read the directions carefully
  • Don’t rush but pace yourself
  • Read the entire question and look for keywords
  • Always read the whole question carefully
  • Don’t make assumptions about what the question might be
  • Keep a positive attitude throughout the whole test and try to stay relaxed. If you start to feel nervous take a few deep breaths to relax.
  • Bring a watch to the test with you so that you can better pace yourself

Best of luck as you enter the certification process!

ACDIS member weds while attending 2009 conference

This cake by Freed's Bakery in Las Vegas bears the title "Lucky in Love"! We're sure happy that ACDIS member Vicki McMahon decided to marry her sweetheart Ron! Talk about lucky!

This cake by Freed's Bakery in Las Vegas bears the title "Lucky in Love"! ACDIS member Vicki McMahon and now hubby Ron tied the knot while there for the conference-talk about lucky!

Vicki and Rod lived in the same small town most of their lives and although they each knew of each other’s families, they’d never met. Then about four years ago, Vicki and a friend decided to go out for dinner and drinks. Rod and his friend played music on the jukebox. They asked the ladies to dance. . .

Ah, romance.

Of course, there weren’t immediate sparks, but over time Rod and Vicki realized how much they enjoyed seeing each other. Soon they were inseparable. In February of 2008, Rod asked Vicki to marry him and of course she said “yes!”

When she signed up for the 2nd Annual ACDIS Conference in Las Vegas the couple joked about having “drive-thru” wedding. “We both laughed and then reality sat in,” says Vicki (now) McMahon RN, MSN, Clinical Documentation and Coding Nurse Manager at St. John’s Hospital in Springfield, IL. “We both lead very busy lives so a formal wedding was totally out of the picture, and besides that is not what we wanted. We played around with the idea and by January that is what we decided we would do.”

The couple kept it a secret from everyone and when they arrived in Vegas on May 12, they checked into their hotel, freshened up, put their “wedding attire” on, and off they went to the court house to pickup their paperwork.

“As we were traveling there, we joked about if we would go through a drive up or a walk through wedding. Yes, we are kinda cheesy that way,” McMahon jokes.

With the appropriate papers in hand however the couple headed over to the Stained Glass Wedding Chapel in downtown Las Vegas, tied the knot, and proceeded to enjoy the Vegas highlights, and of course the ACDIS conference!

“I must say this was one of the better organized conferences I have ever attended,” McMahon says. While she and husband are looking forward to attending next year’s show in Chicago, she says, “I’m not sure what we will do to improve on this trip…”

Congratulations Vicki and Ron from all your ACDIS friends!

ACDIS seeks volunteers for work group projects

Update: These work groups are no longer accepting applications.

ACDIS is forming two work groups and is looking for volunteers to take part in these important projects. Participation in both groups is limited. Please note, you MUST be an ACDIS member in good standing to participate. Committees  include:

1. ACDIS 2010 Annual Conference Committee

As its name implies, the ACDIS 2010 Annual Conference Committee will help us plan and shape next year’s conference in Chicago. The committee will provide feedback on past conferences, help select sessions and speakers for 2010, help us decide on any other conference-related activities, and select our annual CDI Professional of the Year.

2. ACDIS CDI Work Group

The ACDIS CDI Work Group will meet on a regular basis to discuss best practices, definitions, and suggested benchmarks on a number of issues in the CDI profession. Its ultimate goal is to produce a series of best-practice articles available to the ACDIS membership.

Joining this group requires you to view its time commitment, objectives, and to fill out an application form. Please read and download the form here, fill out the necessary information, and e-mail it to ACDIS Director Brian Murphy at

We will have a few members of the ACDIS Advisory Board participating on the ACDIS CDI Work Group as well.

Thanks, and I hope to hear from you on these two important projects.

Brian Murphy, CPC
781-639-1872, ext. 3216

Nurses fight for rights as CDI professionals

Clinical Documentation Specialist?

I was reading an article (title undisclosed) recently that discussed the importance of hiring a CDI specialist in a certain hospital settings. They gave a glowing account of the attributes of the clinical documentation specialist and the benefits they have on the business side of medicine.

The article went on to describe how to select a trained applicant. It recommended that the hospital “select a clinically astute coding professional with a strong business background.” It went on to say that hospitals should “consider hospital coders with a business background as likely candidates, because they not only posses business experience, but they also have clinical knowledge and competency in IV infusion and other related coding areas.”

I was horribly disappointed with the implication that a (nurse) clinical documentation specialist could not do the job.

Last year our hospital hosted a team of CDI specialists from a nearby hospital who wished to gain information on growing their program. At the conclusion of the day the manager told us that prior to coming to our hospital he would not have hired an RN. He thought they were unable to understand coding rules and concepts. After spending the day with us, he no longer felt that way.

At the Florida Regional ACDIS meeting that same manager introduced us to his team and he was especially proud to introduce his newest team member—a nurse.

When are the walls going to come down? A majority of the ACDIS members who attended the meeting in Las Vegas were nurses, yet most of the resources for clinical documentation improvement are are geared for coders. I am confused!

When I made the transition from case management to CDI, I was excited to enter a new and growing field. CDI was presented as a new opportunity for experienced nurses who had a desire to grow professionally. Our department had no policies or procedures, or standards for recording or measuring success. We developed the program from scratch.

I am not a coder but I worked very hard to learn the little bit I have learned about coding. I read many books, have taken many courses and asked many questions. I am a Clinical Documentation Specialist. Why is it, that I am the only person who thinks so?

Feeding the brain on malnutrition documentation

Remember the old 80’s ad for the Big Mac? “Two all beef patties, special sauce, lettuce, cheese,

Documenting malnutrition might be easier than building a Big Mac.

Documenting malnutrition might be easier than building a Big Mac.

pickles, cheese, onions on a sesame seed bun.”

These lyrics and the associated fast food mania was a sign of what I will call food affluence, when we valued time over money, convenience over quality and taste over nutrition. And yet during that same period, the prevalence of malnutrition in hospitalized patients was investigated numerous times with results indicating the malnutrition was a major concern for elderly, hospitalized patients. The effects of malnutrition and the associated costs were also vastly studied in late 80’s and early 90’s. So why has this issue not resolved?

Of course, the issue is once again poor documentation of the severity of the diagnosis and decision making regarding care of this condition. Unfortunately, the malnutrition codes differ from the usual medical terminology. The severity of the malnutrition is indicated in the codes and while clinical severity is typically indicated in risk not actual diagnosis.

Most nutritional consult forms provide a method for the dietitian to indicate risk for malnutrition, not an actual diagnostic statement. Many forms actually ask the dietitian to specify the level of risk of malnutrition by checking the appropriate box for low, medium/moderate, or high. These indicators do not easily translate into an ICD-9-CM code forcing professional coders and CDI specialists to search for other indicators of the severity of malnutrition to clarify diagnoses with the physician.

In an attempt clarify the need to document the severity of malnutrition in adult hospitalized patients, Coding Clinic addressed the issue in the fourth quarter of 1992. It says: