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Did you know: CDI Strategies is free

Time to toot the ACDIS horn again. (I’m getting good enough at it that I might be able to play “Row,

This is probably the only horn I'll ever know how to play. I wonder how many notes I can get it to make?

This is probably the only horn I'll ever know how to play. I wonder how many notes I can get it to make?

Row, Row Your Boat,” but I’ll never be good enough to break out the French horn for anything Mozart might have written. )

Blog readers who are also ACDIS members already know about the multiple opportunities ACDIS provides to glean and share information. However, many readers who are not yet members may not be aware of the variety of free content we offer particularly in the bi-weekly e-newsletter CDI Strategies.

CDI Strategies offers the latest CDI-related news and regulatory updates, tips for day-to-day program improvement and problem-solving, questions and answers from our advisory panel, book excerpts, and more. It comes to your e-mail inbox and is also archived on the Web site

And while I reserve more entertaining, creative musings (what type of horn would one play if they were to tout their own tootings anyway?) to the ACDIS Blog, the CDI Strategies e-newsletter contains a wealth of information that serious CDI specialists need to maintain an effective program.

Okay, putting the horn away for now. Maybe I should try the cowbell next time. Everyone needs more cowbell…

ACDIS CDI Work Group update: Group chosen, work to begin

Hi everyone, I thought I would take a moment to provide an update on an exciting new initiative going on with ACDIS: the CDI Work Group. This is a group that, beginning in the next few weeks, will start a series of bi-weekly meetings to discuss common obstacles and best practices in the field of clinical documentation. Its goal is to produce detailed surveys, benchmarks, and best practices to share with the membership.

I’m personally very excited about this group and strongly believe that the diverse expertise it brings to the table–and the work it ultimately produces–will be of immense value to our ACDIS members.

We had over 50 applicants for the CDI Work Group but in the end we had to narrow it down to 15. The CDI Work Group consists of the following members:

  • Cheryl Ericson, MS, RN, Clinical Documentation Improvement Manager for The Medical University of South Carolina
  • Lisa Peterson, BS, RHIA, Manager of the Medical Record Department for the University of Tennesee Medical Center
  • Jennifer Woodworth, RN, BSN, Manager of Clinical Documentation for MultiCare Health System in Tacoma, WA
  • Glenda Hebert, RN, BSN, CCM, Clinical Documentation Specialist for CHRISTUS Hosptial St. Elizabeth in Texas
  • Susan Payne, RN, BSN, Manager of Case Management/Social Services for Sharp Chula Vista Medical Center in California
  • Eileen Hickey, RHIA, Coordinator of Medical Record Services for Atlantic Health-Morristown Memorial Hospital in New Jersey
  • Karen Frosch, CCS, Clinical Documentation Manager for Christiana Care in Delaware
  • Lena Wilson, RHIA, CCS, Manager of HIM Operations/Clinical Documentation Improvement Program for Clarian Health in Indiana
  • Thenia Nesbeth-Blades, RN, MSN, CDI Specialist for New York Presbyterian Hospital-Columbia
  • Luanne Jennex, RN, CDI Specialist for Westchester Medical Center in New York
  • Donald Butler, RN, BSN, Manager of Clinical Documentation for Pitt Country Memorial Hospital in North Carolina
  • Sue Muse, RHIA, CDI Director for Precyse Solutions in Kentucky
  • Marta Boyd, RN, Documentation Specialist for Valley Hospital and Medical Center in Washington
  • Adelaide LaRosa, RN, Director of the Clinical Documentation Improvement Program for St. Francis Hospital in New York
  • Pat Danks, CCS, CPC, CPC-H, CCDS, Coding Quality and Compliance Consultant for Kindred Healthcare

The group will be directed by three members of the ACDIS Advisory Board, including Shelia Bullock, Wendy DeVreugd, and Garri Garrison. In addition, I’ll be participating as well.

The CDI Work Group will be an ongoing project and will attempt to address many issues within the profession, starting with staffing considerations. Over time we may be looking to add members of different backgrounds and experience to participate, so stay tuned.



Take advantage of opportunities for personal growth

A clinical documentation improvement (CDI) specialists’ focuses  on educating physicians on the

Take advantage of educational opportunities where ever you find them.

Take advantage of educational opportunities where ever you find them.

merits and material benefits of complete, accurate, and effective medical record documentation on the practice of medicine. The CDI specialists’ goal is to affect positive change in physician’s documentation. CDI specialists also help the physician understand and appreciate his/her role in clinical documentation as a proactive and defensive strategy to meet the tough business economic climate challenge of healthcare.

In order to affect positive change and be successful in the role of CDI, the specialist need to view the duties and responsibilities inherent to the position through the eyes of a businessperson. Just as physicians are business people who happen to choose medicine as their line of business, CDI  specialists’ are business people who happen to choose documentation improvement as their line of business.

As a businessperson, the CDI specialists has the responsibility of expanding and continually building upon his/her business skills through personal investment in tools and education as a strategy in becoming more proficient and effective in the business of CDI. It is incumbent upon the CDI  specialist to maintain relevancy in clinical medicine through reading of the medical literature such as JAMA, New England Journal of Medicine, subscribing to Journal Watch publications, Mayo Clinic Proceedings, and other daily newsletters.

Other considerations include subscribing to the Harvard Business Review or Influence without Authority, and investing the time to refresh skills in negotiation and communication through coursework at a local college or adult education class.

A successful and competent CDI specialist will recognize the need for continual education beyond learning the basic CDI crash course taught and promoted by many consulting companies. The likelihood of success of a CDI program rests primarily on the CDI specialist, recognizing the value and worth of proficient business skills as a foundation for the delivery of physician clinical documentation education of long lasting benefit and use to both the institution and the physician.

Quite frankly, there is more to CDI than leaving clinical queries on the record in hopes of the physician answering the query. A CDI specialist can control his/her own destiny through development and honing of business, communication, and negotiation skills.

Let the opportunities begin.

Oregon Chapter to hold meeting in September

Two things happened in the Oregon town of Tualatian in 1951:

  1. The Veterans of Foreign Wars (VFW) Hall that was built on Seneca Street.
  2. The Tualatin River was inundated with crawfish.

Tualatin Crawfish Festival 2009.cdrSo, the good people of the city did what most cities and towns would do, it threw a party and proclaimed it the first annual Crawfish Festival. The sordid history of the celebration includes a battle with Breaux Bridge, Louisiana, a town that proclaims itself the “Crawfish Capitol of the World.” At one point a self-proclaimed Voodoo Queen who lived in Breaux Bridge placed a hex on the Tualatian celebration. Although the hex (and a major riot in the 1970s) nearly ruined the festival the event neverless returned stronger than ever. An estimated 12,000 people were expected to join in the fun for the 2009 event which took place this past weekend August 7-9.

So while we’re sort of sorry the first meeting of the Oregon ACDIS Chapter has to wait until September 18, maybe its a good idea to avoid all talk of voodoo and crawfish when attempting to concentrate on the most appropriate documentation for malnutrition and congestive heart failure.

The meeting is slated for Friday, September 18, 9 a.m. to 2 p.m., at Meridian Park Hospital, 19300 SW 65th Ave., Tualatin, OR. Graciously accomodating those who have had their education and travel budgets trimmed, group organizer Linda Haynes, RHIT, CCDS, says she’ll have a conference line established for those who want to participate but can’t make the trip. If you do plan to attend, call her at 503/692-8864 or e-mail her at

I have no doubt there’ll still be some yummy crawfish for Oregonian day trippers to enjoy so come for the CDI information and stay for supper.

More on potential pitfalls of malnutrition documentation

Johns Hopkins’ Bayview Medical Center in Baltimore agreed to pay nearly $3 million to settle

Make physician documentation regarding malnutrition a matter of black and white.

Make physician documentation regarding malnutrition a matter of black and white.

allegations by two of its inpatient coders that the hospital’s physicians reported secondary diagnoses of malnutrition or acute respiratory failure  not identified or treated, according to a June 30 2009 press release from the United States Attorney for the District of Maryland.

The two coders, whose primary responsibility included assisting with clinical documentation, claimed they were asked to review inpatient medical records to determine whether the hospital could increase reimbursement by changing the severity of certain patients’ secondary diagnoses. Bayview denied all allegations but agreed to pay the settlement to avoid further litigation.  How can you ensure compliant documentation for these conditions and avoid becoming the target of a lawsuit?

The following ICD-9-CM codes denote malnutrition:

  • 263.0, malnutrition, moderate
  • 263.1, malnutrition, mild
  • 263.2, arrested development following protein-calorie
  • malnutrition
  • 263.8, other protein-calorie malnutrition 263.9, unspecified protein-calorie malnutrition

These codes are quite specific and require the physician to document the malnutrition severity. Coding Clinic, fourth quarter 1992, reiterates this point. When coding malnutrition, look for clinical indicators such as lethargy, constipation, skin lesions, and hair loss. Potential treatment for this condition includes calorie counts, daily weigh-ins, and dietary consultations. (Note: These lists
are not comprehensive.)

“I would always look for a dietary consult,” says Kathy DeVault, RHIA, CCS, manager of professional resources at the American Health Information Management Association in Chicago. Coders may not use the dietitian’s notes when assigning codes; however, they can use them as the rationale for submitting a query to the physician.

Related reading:

CMS abandons IPPS payment reduction for now

Though many hospitals feared a 1.9% reduction in payment for 2010, they will actually see a 2.1% increase, according to the fiscal year (FY) 2010 IPPS final rule that CMS released July 31. CMS had originally proposed a documentation and coding adjustment to account for the effect of increases in aggregate payments due to changes in hospital coding practices that it says do not reflect increases in patients’ severity of illness.

The proposed adjustment would have resulted in historically low payments for hospitals and especially penalize hospitals that have yet to develop a clinical documentation improvement (CDI) program, says DeAnne Bloomquist, RHIT, CCS, president and chief consultant for Mid-Continent Coding, Inc. in Overland Park, KS. “I think that means that hospitals can breathe a sigh of relief.”

In the proposed IPPS rule, CMS intended to reduce future payment rates “based on the observed increase in spending due to documentation and coding that occurred in fiscal 2008,” according to CMS’ press release. However, because it does not have a full year of data that would show the extent of documentation and coding effects on 2009, CMS decided not to implement the adjustment until it has a full year of FY 2009 data.

In the next year, hospitals with CDI programs should continue their initiatives, while those who have not implemented one yet should work toward that goal, says Gloryanne Bryant, RHIA, CCS, CCDS, Regional Managing HIM Director at Kaiser Foundation Health Plan Inc & Hospitals.

Documentation requirements for critical care services

In the July 23 issue of CDI Strategies, Robert S. Gold, MD, founder of DCBA, Inc., in Atlanta, offered a tip to help CDI specialists gain physician support for improved documentation in the medical record regarding critical care. In a subsequent e-mail, Gold added comments from his “guru” on physician professional billing, Paul Dickson, MD.

Here is the amended information:

Critical care does not include ongoing monitoring of a patient who has stabilized, regardless of how many organs have failed in the past, but have now stabilized, how many lines and tubes were inserted, or how many devices were instituted. When the patient is stable, it is not critical care.

Too many physicians, however, do not realize that we can bill:

  • Critical care delivery by time increments for the first encounter
  • Additional critical care when the patient crashes again
  • A level three subsequent visit for noncritical care in addition to the critical care delivery on the same day

Any usual evaluation and management (E/M) service appropriate for services and documentation provided may be billed prior to a critical episode, but not vice versa. Consider the following case study.

A patient presents to the cardiac care unit after a coronary artery bypass graft. The patient is intubated with a left ventricular assist device still in place but is not active and receives low-dose dopamine for renal perfusion. The patient’s vital signs are stable with a little hypotension due to lack of vascular tone due to residual effects of anesthesia, however, it is easily controlled. The external pacer is in place, chest tubes are in place to underwater seal, and diluted urine is flowing through the Foley. A physician accepts the patient onto the intensive care unit (ICU) and performs an evaluation. The patient is not critically ill. However, the patient is on a respirator, and the physician manages that respirator. This may be ventilator management 94002-3 alone, and no E /M service may be billed with these codes.

In this case, the patient does not have acute respiratory failure. Writing the words “acute respiratory failure,” means a condition exists that involves the respiratory tree due to a disease process. If, indeed, the patient does have acute respiratory failure due to a disease process when he underwent the surgery, then it is appropriate to document that, if it still exists. If this is not the case, then the presence of the words “acute respiratory failure” will give the heart surgeon a black mark since the condition would be considered a complication of the surgery.

The following are a few examples of conditions that necessitate critical care:


Maryland group names new leaders, launches Web site

Maryland's got a state flag, maybe the CDS Workgroup should have one too?

Maryland's got a state flag, maybe the CDS Workgroup should have one too?

Drafting a flag design was not among Maryland Clinical Documentation Specialists’ (CDS) Workgroup’s accomplishments following its regular meeting earlier this month. We’ll let that task slide since they had so much real clinical documentation information to discuss and legitimate Workgroup items to discuss.

First, the group named new co-chairmen James Nagel, MD ( and Christine Mobley, RN ( They will serve as Co-Chairs for the next fiscal year (until June 30, 2010).

Mobley received her nursing degree at City University in London, England in 1994. Prior to becoming a nurse, she worked as a LPN in several London Hospitals in critical areas. Since moving to the United States in 1994, she worked as case manager, risk manager, and quality control at a Washington, D.C., facility before  joining Prince George’s Hospital Center, a member of Dimensions Healthcare System as a Clinical Documentation Specialist. Thanks to nine years of hard work at Prince George’s Hospital, Mosby was promoted and is currently the Director of Clinical Documentation Department.

Second, the Maryland Hospital Association (MHA) CDS now have a Web page via the MHA Web site. MHA members can obtain a sign in by contacting Dana Bonistalli at

ACDIS launches CDI Boot Camps

You’ve just been named the director of your hospital’s new clinical documentation improvement

For a four-day crash course in CDI try an ACDIS Boot Camp

For a four-day crash course in CDI try an ACDIS Boot Camp

(CDI) program and have the lucky opportunity to hire a handful of new staff. The skill set for this profession is diverse and nuanced. Once you find and hire the perfect candidate you still need to provide detailed education about the levels of expectations associated with their new career.

At the risk of sounding like an infomercial, I’ll come right out and say that these new “Boot Camps” can help. The CDI Boot Camp focuses on:

✓ Medical record review and physician query techniques
✓ MS-DRGs and reimbursement under the IPPS
✓ ICD-9-CM coding rules and regulations
✓ CDI program benchmarking and compliance initiatives

It’s a classroom setting course that discusses how to assess undocumented diagnoses based on clinical indicators; how to implement a step-by-step process for a thorough review; how the IPPS system works and how specific, accurate documentation determines hospital payment; how vital ICD-9-CM coding knowledge is to the overall CDI practice and compliance effectiveness of the facility; how to assess and query physicians regarding problematic diagnoses such as congestive heart failure, sepsis, renal disease, and encephalopathy, to build clinical skill-sets and medical record recognition

Phew, there’s a ton of other information that’s being covered during the four-day course. For more information about the CDI Boot Camp, download the .pdf of the brochure, contact Customer Service at 800/780-0584 or e-mail ACDIS members save $150 off the registration fee.

New York chapters proliferate

A week or so ago, Mr. Murphy announced the start of a new Long Island, New York, ACDIS chapter. We also recently heard from Lois Rubin RN, BSN, CPUR, lead clinical documentation specialist, Case Management Department, at St. Peters Hospital in Albany, NY, regarding the possibility of establishing a group in the northern area of the state.

Map of Fort Orange Albany, NY.

Map of Fort Orange Albany, NY.

Now, Albany (according to the city’s Web site) is home to the oldest continuous settlement in the original 13 English colonies. It’s original fort was built prior to 1614. While the settlement in Jamestown, VA, was established seven years earlier in 1607 it was abandoned in 1699. Furthermore, Jamestown may be a national park and archaeological site but it has none of the original buildings. And before my New England neighbors pick a fight, armed with words like “pilgrims” and “Mayflower” remember the Puritans didn’t land in Massachusetts until 1620.

While not bearing the burden of history shouldered by her home city, Rubin can claim some pretty lengthy experience—she’s been a nurse for 30 years and in CDI for seven, spending the past two years a team leader. Nevertheless, she knows there’s always room to learn from others.

To join the Albany chapter contact her at or by phone at 518/525-108.