RSSRecent Articles

ACDIS announces CDI Professional of the Year

The Association of Clinical Documentation Improvement Specialists recently announced the 2009 CDI Professional of the Year. After reviewing all the nominations, the 2009 ACDIS Conference Committee selected:

Beth Kennedy, RN, BS, CCS

Assistant Director Documentation Improvement

Montefiore Medical Center

Congratulations Beth! Beth recieved free admission to the upcoming ACDIS conference in Las Vegas and will receive her award at our Networking and Awards Luncheon on Thursday, May 14. She will also be featured in the upcoming issue of CDI Journal.

The 2009 ACDIS Conference Committee also awarded two ACDIS members for Recognition of CDI Professional Achievement. The two winners include:

Lynne Spryszak, RN, CPC-A

Senior Consultant

FTI Healthcare (and formerly of Alexian Brothers Medical Center)

Wendy Clesi, RN

Director, Documentation Excellence Department

Ochsner Health System

Along with Beth, Wendy and Lynne will also be honored at the upcoming ACDIS conference.  Congratulations to three very deserving winners.

Finally, please keep those nominations coming for 2010! The voting was extremely close, so if you’d like to re-nominate a candidate for next year, please send me an e-mail.

ACDIS: 1,500 members ready to make a difference in healthcare delivery

I joined the Association of Clinical Documentation Improvement Specialist (ACDIS) as its associate director in November 2008, a little more than a year after its inception. By the close of 2008, more than 1,300 people had joined. In one, seven-day period—March 7-14—54 new members joined ACDIS. During the month of March, nearly 200 people had either become a new member or renewed their membership.

That raises ACDIS’ ranks to more than 1,500 CDI professionals. The growth is overwhelming.

We need to stop for a second and ask ourselves why CDI seems so important. It reminds me of a blog post from New Year’s Day, which considered whether the advancement of CDI might come to exemplify one of the more constructive modifications of our national healthcare system.

“CDI specialists do not merely examine documentation and chastise the errant physician for inappropriate verbiage or a misplaced descriptor,” I wrote at the time. “They facilitate communication across a community that has operated in silos for far too long. They open the door for discussion.”

Please click on this 22-second audio clip adapted from the Florida ACDIS Chapter’s inaugural meeting Friday, March 27. In it, Clare Garrard, RN, DSN,case management manager, at Morton Plant and Mease Dunedin, Clearwater, FL, expresses her belief in the power CDI professionals have to influence the type of healthcare being delivered today.

Get the Flash Player to see the wordTube Media Player.

With a network of like-minded, dedicated professionals all empowered by the great opportunity they now possess it seems impossible that CDI would not impact change. It’s not sentimentality. It’s reality—1,500 members strong.

To learn more about ACDIS visit or call me at 781/639-1872 ext. 3711.

ACDIS conference updates

Remember that FX television show “30 Days”? In the show, Morgan Spurlock (you might remember his Academy Award nominated film Super Size Me) immerses in the life and career of someone else for 30 days. If he took on the role of anyone on the ACDIS team, he’d have a very busy 30 days.

That’s how much time is left before the second annual ACDIS conference and things are moving very quickly.

Only 30 days left until ACDIS 2nd Annual Conference kicks off!

Only 30 days left until ACDIS 2nd Annual Conference kicks off!

  • Early registration discount extended: If you haven’t signed up for the conference yet, do so by this Friday, April 17 to  save $100. Contact ACDIS Member Relations Specialist Susan Calabro at or by phone at 781-639-1872, ext. 3116.
  • Room rates: We have negotiated a reduced room rate for conference attendees of $169 per night through Monday, April 23. If you are a government employee be sure to ask Caesar’s Palace for the $126 room rate.
  • CCDS registration deadline: The deadline to register for the Saturday, May 16, seating for the Certified Clinical Documentation Specialist credentialing examination is Monday, May 4. We cannot accept on-site registrations for this exam. If you want to take the test in Las Vegas please register as soon as possible.
  • Exhibitor slots still open: The number of exhibitors scheduled for the conference has more than doubled since last year. We’re extremely excited that more than a dozen business are coming to share their expertise with ACDIS participants.
    Special thanks goes to Gold Sponsor 3M and Silver Sponsors Salar, Inc., DCBA, Inc., The Claro Group, LLC., and NHS Solutions. Of course there’s room for additional exhibitors. For information e-mail Exhibit Sales Manager Margo Padios at or call her at 781-639-1872 ext. 3145.
  • CDI Professional of the Year: Congratulations to the selected CDI Professional of the Year. All our nominees came highly recommended but only one could be chosen. I’ll not spoil the fun, except to say this person has been notified and will receive free conference admission. The award ceremony takes place Thursday, May 14, noon-1:30 p.m.
  • Vegas on-site pre-registration: When you arrive in Vegas, please take a minute to pre-register for the conference. This will help you to avoid long lines prior to conference start-time. The pre-registration room will be open Wednesday, May 13, 4:30-7 p.m., on the Promenade Level of Caesars Palace in Office Four. This way you’ll have more time to enjoy breakfast and catch up with colleagues on Thursday. And when you register, you’ll get your cool new purple bag and all your conference materials (I hear there’s going to be some really neat stuff inside the bags too!)

See what I mean? Luckily we’ve got a great team of dedicated professionals working behind the scenes to make sure the ACDIS conference provides not only the best possible information for clinical documentation improvement specialists but all the networking assistance you need.

On second thought, since Spurlock’s show is officially off the air maybe he’d like to give us a hand.

AHIMA to start CDI work group

Back in March, AHIMA sent out the call for volunteers to help establish a new work group on clinical documentation improvement. The initiative comes as part of the association’s e-HIM effort and aims to determine industry needs and CDI best practices, according to a release.

“We were overwhelmed with the number of people who wanted to volunteer,” says Kathy DeVault, RHIA, CCS, manager of professional practice resources at AHIMA in Chicago.

ACDIS Advisory Board members are among the list of volunteers. DeVault planned to notify participants and begin a series of weekly, work-group calls in early April but the influx of interest pushed the start date back slightly.

CMS releases crosswalk for ICD-9 to ICD-10 translation

CMS released The General Equivalence Mappings – ICD-9-CM To and From ICD-10-CM and ICD-10-PCS Fact Sheet in March to assist in the conversion of ICD-9-CM to the anticipated October 1, 2013 implementation date for ICD-10-CM codes. The fact sheet explains how to translate 9 codes to 10 codes and vice versa.

CMS also release information from The General Equivalence Mappings information discussed in the fact sheet is also posted in the CMS Frequently Asked Questions database.

Coders deserve ‘superhero’ kudos

Hidden deep within the HIM office hides the coders’ universe. These hard working individuals put in long hours at small cubicles, staring at multiple computer screens. They are the unsung heroes of the hospital. This group of individuals would probably shun any fancy accolades, tell you they are simply doing their job, but this is an understatement.

Coders deserve a hero's recognition.

Coders deserve a hero's recognition.

The coder is a type of superhero, bestowed with powers beyond that of a mere mortal. Physicians frequently use abbreviations that boggle the mind. Web sites abound with dictionaries for approved abbreviations, but low and behold the physician will always come up with something new. GLM, for example, sometimes refers to a patients’ good looking mother. ARBF means awaiting return of bowel function. The list goes on and on, but curiously the coders know what the collection of symbols stand for.

Coders also decipher the worst handwriting in the universe and make sense out of the senseless. They memorize physician signatures and read words where others only see squiggles. Coders know the DRG number of most illnesses.

Hospital reimbursement would come to a standstill were it not for the coders, making them more powerful than a locomotive. The “super coder” can read through a chart faster than a speeding bullet. They may not be able to leap tall buildings, but they sure can find the principle diagnoses in a single bound.

The Clinical Documentation Improvement department is still fairly new to the hospital scene and the profession has gone through many changes even within that period of time. Coders have been an integral component throughout this transition and it is clear that these modest groups of individuals are SUPER!

Have a CDI position fill? Tell us about it.

In the past seven days more than 30 new clinical documentation improvement specialist job openings have been posted on the World Wide Web, according to a quick search on CDI keeps growing and growing.

ACDIS wants to help you and your facility as you search for new professionals to join your documentation improvement team. Soon, we’ll launch a Web page that allows members to log in and post up to four open positions per year. Anyone who is not a member but wishes to post open positions can contact our customer service department at 800-650-6787. Prior to the page’s “go-live” date, please e-mail ACDIS Associate Director Melissa Varnavas at with the following information:

Job Title:
Name of Facility/Hospital:
Location of Facility/Hospital:
Contact Person:
Contact Address: (e-mail address)
Content Phone Number:
Job Description (only one job description per posting please maximum 300 words):
Preferred start date:
Please indicate if position is full-time or part-time; permanent, contract, or consultant

Chemotherapy documentation challenges warrant CDI attention

Given the extremely high cost of chemotherapy services, it is likely that third-party payers, including Medicare, will scrutinize these services, says Glenn Krauss RHIA, CCS, CCS-P, C-CDIS, in an article for

Here is a breakdown of areas generally targeted by payers including Medicare and their related documentation difficulty:

  • Medical necessity for the supplied diagnosis: Often the clinician fails to provide the specific location of the cancer. A clinical documentation specialist can query the physician to ensure appropriate documentation.
  • Coverage exclusion for specific drugs based on clinical trial effectiveness:  Coders should reference local coverage determinations that generally spell out which diagnoses are considered covered benefits for common chemotherapeutic agents.
  • Proper charging and billing of drug units: Just documenting patients’ nausea and vomiting is not always sufficient to support payment of anti-emetic medicines.
  • Documentation to support IV administration units of service: Accurate coding for this requires clear start and stop times for IV chemotherapy administration. It is particularly problematic because clinicians do not always document the order of sequential therapy.

CDI programs might consider designating a team member specifically for the chemotherapy service line, Krauss says. A part-time specialist or member of the existing team may be enough depending on the monthly volume of patients in the chemotherapy department and the number of new patients who begin chemotherapy each month.

Focus initially on validating documentation and providing feedback to clinicians regarding documentation of IV therapy administration. The CDI specialist can help bridge the gap between customary medical record documentation and the level and detail of documentation necessary to properly and accurately capture all IV administration charges. subscribers can read the complete article online. 

Three tips to maximize the role of physician advisor

It’s been a year or so since you’ve started your CDI program. So far, so good. The administration thinks your team took miracle-worker training. So much so, they’ve agreed to let you add a physician advisor (PA) to the staff. And you’re all for it. You know a PA will add credibility to your documentation improvement efforts, act as a liason with difficult physicians, and help your staff memebers investigate documentation deterrents. Here’s how:

  1. Disseminate CDI program goals: CDI specialist’s struggle to strike just the right documentation chord to win physician support. Improved documentation equals better patient care, improved scores on the physician’s scorecard, improved hospital care, and of course the elephant in the room no one’s supposed to mention—better reimburment. While the primary goals of CDI programs are indeed the improved care of the patient, physicians sometime think the facility cares only about the bottom line. A PA who puts his support behind the CDI program explore the benefits in a concrete way that a CDI specialist with coding or nursing background cannot.
  2. Define communication issues and barriers: Maintain a consistent dialogue with your PA. Allow him or her to bring you constructive criticism from fellow physicians. Maybe cardiologists hate it when CDI specialists bug them at lunch time. Maybe the internists, however, think lunch time is the best time for documentation education. In this way the PA can provide invaluable tips for how to perform better.
  3. Update CDI team on relevant clinical issues: Ask your PA to review existing physician query forms and offer suggestions for how to improve them. Inaccurate, or clinically vague query forms cause physicians confusion. A PA who can head off these potential disputes can help put your CDI program ahead of the game. It’s a physician’s role to understand the latest clinical research. They can help your team understand it too.

Join Mark S. Michelman, MD, MBA, (Morton Plant Mease Health Care System) and Trey La Charité, MD (University of Tennessee Clinical Documentation Integrity Project) for the ACDIS audio conference “Physician Advisors in CDI: Take a Team Approach to Achieve Success and Credibility” on Tuesday, April 14, at 1 p.m. (Eastern).

On the program, the duo will discuss strategies to establish a successful CDI team structure, types of expectations and limitations you should place on your PA, as well as methods to quantitatively measure the progress of your PA and CDI team.

Spring ideas to woo physician support

Chocolate bunnies, marshmallow chicks, and jelly beans all bring to mind the magic of springtime. Fill a clear bag with fake grass and a few candies, tie it with a ribbon and attach your business card.

A little sweetness goes a long way.

A little sweetness goes a long way.

You now have a great little thank you gift for your physicians and allied health professionals. We are all just children at heart and even the most serious surgeon will crack a smile when he sees the festive little treats. It doesn’t take a big budget to let someone know they are appreciated. Include a few documentation items, such as pocket cards, and hospital pens and now you are getting two for one—appreciation and education. This practice of passing out goodies can also be repeated for fall and winter holidays, keeping documentation fresh on the minds of your medical staff.

Keep your creative side open to suggestions when dealing with difficult doctors. Share your ideas with others and together, everyone can reap the rewards.