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How to make a CDIS

While those of us at ACDIS are already working as CDIS there are nurses and coders out there who e-mail me and ask how to become a CDIS so I thought I’d write about what I look for when I’m hiring someone.  FYI, folks, opinions ahead. [more]

AHIMA Takes Second Look at Revised Physician Query Practice Brief

handsBrian Murphy, director of ACDIS, asked me to say something about AHIMA’s decision to revise the Physician Query Practice Brief and provide some commentary on the first draft.  While I’m unable to provide the complete text here I’ll try and paraphrase the sections that, in my opinion, still need some clarification and I’ll give some examples of the sections that I agree with.

The revised brief is presented in two sections:

  1. the first addresses current legal, regulatory and ethical issues, documentation, the query process
  2. the second part provides direction concerning compliance; specifically, auditing and monitoring and reporting and performance metrics

What the brief does not do is answer the all-time burning question “what constitutes a leading query?” or acknowledge that there is a difference between a nurse asking a physician a question (clinician-to-clinician) and a coder querying the physician.  I feel that the “guidance” provided in the first draft does anything but guide.


ACDIS Conference I: Highlights

caesarsWhat can I say about our first ACDIS conference that will adequately describe the excitement and satisfaction I felt to be surrounded by so many of my peers? 

I had been looking forward to this time ever since the dates had been announced.  When I walked out of the airport to catch the hotel shuttle, saw the palm trees (photo-op!) and felt the warm weather (thank you Lord, for 80 degrees after a Chicago winter) I knew I wasn’t “in Kansas anymore”.

From the time that I walked into the marble-floored lobby of Caesar’s Palace until I left to return home every hour was packed with experiences that I won’t soon forget.  I arrived late Wednesday morning, the day before the conference started, so that I would have time to check into the hotel and get my bearings.  [more]

CDI Talk: When in Doubt, Call a Friend

discussionIf you haven’t joined in the discussions taking place on “CDI Talk” you’re missing out on a wealth of information.  Some of the recent discussion topics (to name only a few) have been: query forms, BMI,  querying for decubitus ulcers, POA, RACs, to name just a few.

You don’t have to be an expert to join in; in fact, questions from new Documentation Specialists are often trigger the most lively discussions!  One topic from 3/26 titled “What DRG would you assign” received 25 responses!  This topic was a great example of how CDIS see situations differently and the supporting arguments presented were well thought out and detailed. [more]

RAC – Who and What are They and Why Should I Care?

While we’ve been busy working our fingers to the bone performing our chart reviews CMS has been diligently working to come up with ONE MORE THING that will ultimately involve CDI Specialists: the RAC program.

The RAC (Recovery Audit Contractor) program is an outcome of section 306 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA). As part of this Act Congress directed the Department of Health and Human Services (DHHS) to conduct a 3-year demonstration program using Recovery Audit Contractors (RACs) to detect and correct improper payments in the Medicare FFS program.

In addition, in section 302 of the Tax Relief and Health Care Act of 2006 (TRHCA), Congress required DHHS to make the RAC program permanent and nationwide by no later than January 1, 2010. [more]

What challenges are you facing? Let’s hear from you

Sometimes it’s difficult to find the time to write a post, but I have a good excuse:  I’m busier now than ever since MS-DRGs rolled around. Our CDI team has been developing new query templates, searching out obscure secondary diagnoses and has beenhot on the trail of substantiating conditions present on admission. Sound familiar? [more]

Welcome to CDI Blog

I’m honored to be asked to write the first post for our soon-to-be-famous CDI Blog! There are so many wonderful people involved with the ACDIS, many whom I’ve met over the phone and many over the internet. The internet is really a great tool: it allows us to communicate instantly and directly with one or many, share our ideas and it’s a wonderful venue for building our community: that of Clinical Documentation Specialists.

What we do is hard to explain to outsiders.  It involves the ability to read a patient’s chart, understand their diagnosis and treatment plan and to identify whether the documentation in the record, once translated into ICD-9 codes, will paint an accurate picture of their inpatient stay.  Our efforts impact a facility’s public quality ratings, affect physician profiles, and determine the revenue a hospital receives. [more]