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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:


CDI Journal posted on

The third quarter CDI Journal has been posted and is available for ACDIS members online at

Here’s a list of what’s included inside the July edition:

Director’s note
ACDIS members make conference a success. What will happen in Chicago?
Case study
CDI Professional of the Year Beth Kennedy earns kudos. CDI Professional Achievement honorees noticed for teamwork and leadership skills.
Malnutrition documentation
Guest columnist Jon W. Arnott, MD, CMQ, explores how to capture severity of illness through malnutrition indicators; includes sample query form and clinical data set.
Query protocols ease compliance risk
Setting appropriate query standards can keep potentially harmful practices at bay.
Inflammatory bowel disease
Guest columnist Helen Walker, MD, writes about the tricks of capturing accurate language for a host of possible gastrointestinal problems; includes sample query.

CCDS designees named
ACDIS is proud to recognize and congratulate our first group of professionals to pass the Certified Clinical Documentation Specialist (CCDS) exam. They are now free to begin using the CCDS credential after their name.

RAC: Complex reviews to arrive as soon as August

Those who haven’t seen the latest e-mail news blast, I thought I’d post it again here.

by Andrea Kraynak, CPC-A

CMS released further information June 24 on its RAC Web site letting healthcare providers know when they can expect RACs to begin auditing. The new “CMS RAC Review Phase-in Strategy,” details different types of reviews and dates CMS anticipates the reviews will begin in various areas of the country.

The new information is consistent with CMS’ previous indications that some providers may begin to undergo automated review this month.

According to the CMS, the earliest possible dates for RAC reviews in yellow and green states are:

  • June 2009—Automated reviews of black and white issues
  • August or September 2009—Complex reviews for DRG validation
  • August or September 2009—Complex review for coding errors
  • Fiscal year 2010, which begins October 1, 2009—Complex reviews for durable medical equipment (DME) medical necessity
  • Calendar year 2010—Complex reviews for medical necessity

The earliest possible dates for reviews in blue states generally fall a bit later:

  • August 2009—Automated reviews of black and white issues
  • October or November 2009—Complex reviews for DRG validation
  • October or November 2009—Complex review for coding errors
  • Fiscal year 2010—Complex reviews for DME medical necessity
  • Calendar year 2010—Complex reviews for medical necessity

CMS also reaffirmed that before RACs actively begin auditing in a particular state, outreach educational sessions must occur in that area.

Although the schedule calls for automated reviews as early as this month, any issue a RAC reviews must be vetted through the CMS’ “Issue Review Board.” In addition, RACs must post the approved issues to their Web sites before the reviews can begin.

“Providers should check their RAC’s Web site often for any newly approved issues for review to anticipate their vulnerability to reviews and take backs,” says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc.

Even though CMS has delayed the rollout of certain types of complex reviews, providers shouldn’t ease off on their RAC preparation activities.

“Use the time wisely to continue performing your own internal vulnerability audits and ensure that all of your policies and procedures are up-to-date. Consider this a little extra time to get your facility ready for those appeals,” says Tanja Twist, MBA/HCM, director of patient financial services at Methodist Hospital of Southern California.

Note: Twist and Hoy will be speaking at the upcoming conference, “Medicare Compliance Forum: A Strategic Approach to RACs, Observation Status and the Role of Physician Advisors,” which will be held in Atlanta this October. Twist will also be featured in the July 21 HCPro audio conference, Medicare Appeals: Practical and Compliant Procedures for Overturning Denials.

New ACDIS white paper available for download–encephalopathy

Hi ACDIS members, I wanted to let you know about a new white paper available for download in the Helpful Resources section of our Web site under the heading “White Papers.” It’s called “Cut through the confusion of altered mental status,” and it offers suggestions on what to when physicians document AMS, as well as how to appropriately query for encephalopathy and/or other more specific diagnoses. It also includes a sample AHIMA-compliant query form.

The source of the white paper is James Kennedy, MD, CCS, of FTI Healthcare. Dr. Kennedy is a unique combination of clinical and coding expertise.

I hope you find this white paper helpful. ACDIS publishes white papers on a quarterly basis on various topics in the CDI profession. If you haven’t seen our Helpful Resources page, check it out!

Take care,


Chapter 3: The MS-DRG Training Handbook

We’re constantly talking about to get the word out about the importance of clinical documentation improvement. How can we teach physicians that the specific language they use in the medical record affects their patient’s treatment, their quality scoring, hospital reimbursement, and their own reimbursement too?

First to answer the triva questions wins a set!

First to answer the triva questions wins a set!

Some of you may be familiar with The MS-DRG Training Handbook written by ACDIS Advisory Board member Gloryanne Bryant, BS, RHIA, RHIT, CCS, but for those who haven’t seen it yet there’s a collection of examples for explaining the MS-DRG system to physicians in Chapter 3, I thought I’d share with you:

“1. Call upon physicians to better document the character, underlying causes, complications, and severity using ICD-9-CM language. For example, in order to get decompensated CHF to count as an MCC, physicians must clearly state that it is acute and must document whether it is systolic or diastolic heart failure. Stating one without the other will result only in a CC.

“2. Ask physicians to clearly document the underlying mechanisms of certain manifestations. For example, if a patient has hyperkalemia as the result of the drug spironolactone, the physician needs to document the state of hypoaldosteronism. Similarly, if a patient has delirium due to narcotics, the CDI specialist needs to query the physician regarding the extent or possibility of toxic encephalopathy. “

The Handbook includes a good amount of basic, easy-to-understand information regarding the development and importance of the MS-DRG system, which I’m sure I’ll excerpt from again. Not to be pushing product but it comes in packs of 10, which. . . when we’re talking about educating physicians. . . can be a quick item for CDI specialists to hand out.

Educating physicians and others  about how the implementation of MS-DRGs increased the need for CDI is particularly important during a new CDI program’s inception. That’s when the only thing physicians want to know is: Who are you? Why are you doing this? What’s in it for me? Understanding MS-DRG basics can help them see the bigger picture behind the healthcare reimbursement system.

So here’s some trivia. First person to answer BOTH questions correctly will get a pack of the Handbooks.

  1. When did the MS-DRG system take affect?
  2. What three basic categories of the system?