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Local Chapter Update: Upcoming meetings and events

32671-ACDIS-local-chapter-logo_largeACDIS local chapters come in many shapes and sizes. Some meet regularly by phone. Others meet for a couple of hours in the morning for an educational session and some networking before returning to their routines after lunch. Still others meet quarterly for all-day or nearly all-day events. And local chapters are growing.

In ACDIS’ early years, there were only three or four state, or regional, focused networking groups. Those groups gathered a dozen or two dozen participants. Fast forward nine years and some of those groups now have rosters with hundreds of names and meetings with hundreds of participants.

With such growth often comes some growing pains. As costs for hosting events rise, the volunteer leaders look to sponsors to help defray the costs and begin to collect dues from their membership. Such activities require a level of forethought and formality. Volunteer leaders need to draft chapter bylaws, create policies for vendor involvement, research local laws related to becoming a non-profit organization, and organize their team to handle the financial responsibilities required.

There is no direct financial relationship between ACDIS national and these local organizations. Although national provides an extensive toolkit of sample policies and procedures, bylaws, and event tips, the volunteers who organize local events are just that, volunteers. They donate their time, energy, know-how, and love of CDI to help advance the profession. If you have the opportunity to attend one of these upcoming events, please seek out these amazing people and thank them for their efforts.


  • The Philadelphia-area Pennsylvania/New Jersey ACDIS Chapter meets Thursday, August 4, at 8 a.m., at Our Lady of Lourdes in Camden. For information, contact Gina Stewart at
  • The North Carolina ACDIS Chapter meets Friday, August 5, at Wake Forest Baptist Medical Center, in Winston Salem. Registration is a two-step process: First, complete the conference registration form, then, enter your NC ACDIS registration fees, online, here. For information, email
  • The Georgia ACDIS Chapter meets Friday, August 12, 8 a.m. to 3 p.m., at Tift Regional Medical Center in Tifton. For information, contact
  • The Indiana and Kentucky ACDIS Chapters join for a regional event Friday, August 19, 8 a.m. to 4 p.m., at the Louisville (Kentucky) Marriott East. Click here to read the complete agenda. Click here to download the registration form. Deadline for registration is August 5. For information, contact Rita Fields at rita.fields@BHSI.COM.
  • The Utah ACDIS Chapter meets Wednesday, August 17, at the University of Utah for a discussion with Russell Vinik, MD, Medical Director for CDI at the facility. For information, contact Molly Evans at
  • The New Jersey networking group meets on Friday, August 19, 10 a.m. to 3 p.m., at Centrastate Medical Center in Freehold. Glenn Krauss, director of enterprise solutions at ZiRMED will present “CDI- Achieving the Potential.” To register, click here. For additional information, email Deborah Gardner-Brown at
  • The California ACDIS Chapter meets August 24, 9 a.m., via webinar, to discuss “Leveraging the physician value based payment modifier,” with Richard Pinson, MD, and Cynthia Tang. For information, contact Shiloh Williams at

Save the date: September

  • The South Carolina ACDIS Chapter meets Friday, September 16, at Providence Hospital in Columbia. For information, contact Mary Hopkins at
  • The Maryland ACDIS Chapter meets Friday, September 16, 9 a.m. to 3 p.m., at the Maryland Hospital Association. Registration is nearing capacity. For additional information, email Olga Firstbrook at
  • The Tennessee ACDIS Chapter joins THIMA, and the Tennessee Hospital Association for a CDI summit on Thursday, September 22, at the THA offices in Nashville. For information, contact Sherri Clark
  • The Maine ACDIS Chapter meets Friday, September 23, at Eastern Maine Medical Center, noon to 4 p.m. For information, email
  • The ACDIS NW Oregon Chapter meets bi-annually. The next meeting will take place on September 30 in Medford. For information, contact Karen Gray at

Save the date: October

  • Three Missouri ACDIS chapters join together for their first state-wide full-day event on Saturday, October 15, at Boone Hospital Center in Columbia. For information, contact Karen Elmore



Q&A: Procedure code for esophagogastroduodenoscopy

Got a question? Ask us!

Got a question? Ask us!

Q: What is the correct procedure code for an esophagogastroduodenoscopy with placement of clips to control bleeding? Our coder coded 0DQ68ZZ, which groups to DRG 326, the same as an esophagectomy. The relative weight (RW) is 5.45. This does not seem right. Could you please clarify?

A: This was addressed in AHA Coding Clinic for ICD-9-CM, Fourth Quarter, 2014. The coder is correct in their assignment. The only difference is that this was in the esophagus, but the intent is the same. I am assuming it is because the clips act as a “suture” to stop the bleed, and therefore it is considered a “repair,” much like suturing for the integumentary system.

Coding Clinic states:


A patient presents with bleeding duodenal ulcer and an esophagogastroduodenoscopy was carried out. Multiple clips were applied to the vessels to control the multiple hemorrhaging ulcers. Should “control” be assigned for the root operation? What is the ap­propriate ICD-10-PCS procedure code?


The root operation “control” is defined as only applicable for procedures to correct postoperative bleeding, and so it does not apply to this procedure. This procedure is a repair of the duodenum. Most of the body’s organs and tissues are vascular, and they bleed when cut or eroded. Repair of a cut or eroded body part is coded to the body part repaired, rather than to a vascular system body part. In this case, the duodenal ulcers are being repaired via an endoscop­ic approach, with clips placed on vessels eroded by the ulcers. Assign the following ICD-10-PCS code: 0DQ98ZZ Repair duodenum, via natural or artificial opening endoscopic.

I think why this seems so problematic is that in ICD-9-CM, the code would likely be 42.33, endoscopic excision or destruction of lesion or tissue of esophagus, which includes control of esophageal bleeding and was considered a non-operating room procedure. The ICD-9-CM code was very generic. When translating to an ICD-10 code, the intent of the procedure seems to have been taken into consideration. This procedure is the same intent as suturing sites like the duodenum and stomach for bleeding, which was assigned to a surgical DRG. This would be my guess as to why it maps to DRG 326, though I agree that the RW seems very high.

Editor’s note: Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS Director of HIM/Coding for HCPro in Middleton, Massachusetts answered this question. Contact her at For information regarding CDI Boot Camps visit

Radio Recap: Defining acute respiratory failure in provider documentation

26596_ACDIS-Radio-logoWhat’s the biggest issue related to for reporting respiratory failure diagnoses? It all starts with the definition, said Robert Stein, MD, FCCP, CCDS, associate director of the MS-DRG assurance program for Enjoin, during the July 13, 2016 ACDIS Radio broadcast.

At his former practice, Stein said each of the six pulmonologists had a different definition of acute respiratory failure. Provider documentation of this condition in the medical record is often unclear, not only due to inconsistent definitions, but also as a result of loosely-used terminology, such as “respiratory distress” versus “respiratory failure.”

“At the end of the day, a lack of a consistent definition that all providers can follow is the biggest issue.”

Identifying clinical indicators that support acute respiratory failure could result in improved documentation, said Stein.

Acute respiratory failure represents a potentially life-threatening condition that requires hospitalization. During the program, Stein offered his insight as a pulmonologist by providing possible definitions and clinical indicators for acute hypoxic or hypercapnic respiratory failure:

  • Hypoxemic respiratory failure means that the patient does not have enough oxygen in their blood, while their levels of carbon dioxide are close to normal. Clinical indicators include a PaO2 of less than 60 mmHg or arterial oxygen saturation that is less than 90%.
  • Hypercapnic respiratory failure means there’s too much carbon dioxide in the blood, and normal or not enough oxygen. Clinical indicators in this case include an elevated Pco2 of 50 millimeters of mercury (though Stein says some use 45 millimeters) and a reduction in pH of less than 7.35.

Stein looks for signs of increased work of breathing, which supports the premise that the patient is in acute distress. Documentation could include an elevated respiratory rate of roughly 26-28 breaths per minute or “difficulty speaking in full sentences,” said Stein.

The next piece is intervention, which, for an acute respiratory failure patient, could include O2 supplementation or bypass intervention. Finally, increased resource use indicates the level of the life threatening condition, Stein said. If the patient is admitted with a life-threating disorder, they will require at least a monitor bed, if not an intensive care unit bed.

“The doctors will tend to agree on the definitions,” says Stein. “It’s the other points, the indicators, where there’s some divergence and an opportunity for CDI to [collaborate with coders, physicians, and other staff to determine facility-wide guidelines].”

Editor’s note: ACDIS Radio is a bi-weekly talk show covering the hottest topics in CDI. Tune in every other Wednesday at 11:30 a.m. ET. To listen to past shows, click here.

Featured Member: Our 5,000th ACDIS member


Mercedita Morales, RN, BSN

Like dozens of other attendees at this year’s ACDIS Conference in Atlanta, Georgia, Mercedita Morales, RN, BSN stopped by our booth to sign up for an ACDIS membership. Little did she know that she would be the 5,000th person to become a part of our association. A CDI specialist at St. Joseph Health System in Irvine, California, Morales is an active member of the California ACDIS Chapter.

Morales is happily married with two daughters and two grandsons. She loves spending time with her family and enjoys beach days and traveling. We caught up with her about her CDI experience and how it feels to be our 5,000th member.

ACDIS: What did you do before entering CDI?

Morales: I worked as a clinical nurse in critical care, observation, and outpatient procedural units. I also worked as an observation charge capture specialist prior to becoming a CDI specialist.

ACDIS: Why did you get into the CDI field?
Morales: I decided to enter the CDI field because I was interested in exploring other areas of nursing. I wanted to challenge myself in my career and look for opportunities for growth.

ACDIS: What has been your biggest challenge and biggest reward?

Morales: It was challenging initially because I had no prior CDI experience or education. However, the biggest reward is working with a great CDI team and very supportive leadership in our organization who understand the value and impact of the work we do as CDI specialists.

ACDIS: Why did you join ACDIS?

Morales: I joined ACDIS because it is an established organization for all professionals working in this field, which offers members vast professional resources, networking, and education. I believe being a member of a national organization proves that you are committed to your profession because you want to keep up-to-date with the latest best practices and guidelines.

ACDIS: What do you hope to gain from being a member of ACDIS?

Morales: Valuable educational opportunities and resources that I can use and apply to my work.

ACDIS: What piece of advice would you offer to a new CDI specialist?

Morales: I would say it’s important to be persistent, flexible, and willing to learn. Also, to use your resources—there are so many tools out there to help us out.

ACDIS: Tell us a few of your favorite things?

  • Vacation spots: I enjoy going to the beach—especially San Diego, Philippines, and Hawaii
  • Hobby:Gardening
  • Non-alcoholic beverage:Green tea
  • Foods:All types of Asian food
  • Activity: Spending time with my family

Editor’s note: The ACDIS Blog introduces an ACDIS member every week. If you would like to be featured or know someone who would, please email ACDIS Editor Katy Rushlau at

Career Center: This week’s new job postings  

career-centerThe new ACDIS Career Center allows you to upload your resume, browse open positions, and sign up for alerts about new jobs specific to your criteria. If you’re looking to hire, we have job posting options (discounted for ACDIS members) as well as the ability to browse our resume database. Click here to learn more.

Here are the latest job postings:


Guest Post: CDI as chart traffic control


One of my favorite occupational movies is Pushing Tin. Its take on air traffic control is from before 9/11, and just to make it more interesting, it stars actors familiar to the Gen-X population (John Cusack, Billy Bob Thornton, Angelina Jolie, and Cate Blanchett). Of note, the dialogue includes a tongue-in-cheek observation: pilots don’t actually land the planes—the air traffic controllers do.

This sarcasm reminded me of what happens with the medical chart—no matter what the providers write (and despite what diagnoses are still “up in the air”), CDI specialists are there to guide the chart to where it needs to land…hopefully without a “crash and burn” moment. Here are a few ways in which we do that:

  • Present on admission (POA) clarification: Just as a pilot needs to request permission to take off, we must also request information such as POA in order to properly assign a working DRG. Putting a diagnosis that wasn’t POA in the principal diagnosis spot can be akin to a flight path headed toward Spokane when you thought you were going to San Diego. You’ll wind up in the wrong place.
  • Consistency in documentation: Planes pass through various airspaces during longer flights, with handoffs between air traffic controllers (see one example at A Flight Across America – FAA). Safely landing the plane depends on smooth transitions. In patient care, lengthier patient stays can mean that several providers from different service lines will be documenting in the chart. Despite the electronic medical records’ copy and paste functions, charting can be like the whisper game…what was said at the beginning comes out distorted at the end. CDI specialists keep the chart on the path to appropriate and compliant coding and billing. This can even mean querying retrospectively when the discharge summary is missing key diagnoses.
  • Case mix index (CMI) improvement and recover audit contractor (RAC) audit-proofing: – An air traffic controller has several airplanes to navigate on his or her scope. They are keenly aware of airport and airspace traffic. CDI specialists are also privy to environmental information, such as which providers are consistently documenting symptoms instead of diagnoses and which diagnoses are being further scrutinized by the RAC for clinical validation. With our bird’s eye views, both air traffic controllers and CDI specialists strategize for efficiency and optimal outcome. An air traffic controller aims to get more flights to arrive on time and safely; a CDI specialist strives to increase the CMI through educating providers and clarifying diagnoses without clinical support.
  • Allowing for “flexibility within the form:” Sometimes, an air traffic controller has a high volume of aircraft in the airspace at one time. This can mean that one or more planes need to “take a spin” in the sky before being lined up for approach to the airport. CDI specialists also must demonstrate this flexibility in terms of diagnoses. Patient condition and timing of documentation and diagnostics will sometimes require us to be patient and wait until the next day to place a query. Ebb and flow is important in both positions.
  • Participation in safety initiatives: One statistic quoted in the film is that an air traffic controller is in charge of more lives in a shift than a surgeon is in his or her entire career. There is only a certain amount of “near misses” allowed in air traffic control (under three in a two and a half year period, according to the movie) before a controller is pulled from the job. Health care providers are also under scrutiny for never events and hospital acquired conditions, and CDI specialists place queries to help with PSI and HAC documentation.

Although one of the requirements to become an FAA air traffic controller is to enter the FAA Academy before your 31st birthday (oh, how that ship has long ago sailed!), it’s still possible to practice chart traffic control from the comfort of your facility by being a CDI specialist. It can be a thankless, “unseen” job, but in both air traffic control and CDI, things run smoother with us than without us!

Editor’s note: This article was originally published and written by Wendy Frushon Tsaninos, RN, MSTD, CCDS, CMSRN, CCS, Lead Clinical Documentation Improvement Specialist at Maxim Health Information. Connect with her on LinkedIn by clicking here.

Tip Tuesday: CMS quality measures that affect CDI

tips-newsletterWe recently got an e-mail from a customer asking us for a comprehensive list of CMS quality measures that CDI specialists should be aware of. Our lovely boot camp instructor, Sharme Brodie, RN, CCDS, CDI education specialist for HCPro in Middleton, Massachusetts, put together this handy spreadsheet highlighting the different measures and where the information is pulled from. Please note—this information pertains to quality measures as of July 2016 only, and will be outdated by next year at this time. ACDIS members can click here to access.

Want more information and training on quality? Consider signing up for out CDI for Quality Boot Camp. This intensive three-day course is available live and online, and covers publically reported quality data and how code assignment affects quality metrics, including (but not limited to) the Hospital Value-Based Purchasing Program. Students learn the why and how of reviewing complex cases involving Patient Safety Indicators (PSI) and hospital-acquired infections (HAI), and leave with measurable strategies for improving their hospital profiles and positively influencing their facility’s value-based incentive payments. Click here for more information.


A Note From the CCDS Coordinator: You can do what Sarah did, it just takes hard work


Sarah LaSource

by Penny Richards

Sarah LaSource didn’t set out to do anything extraordinary on July 8. She took the CCDS certification exam—and lots of folks have done that. But she did what no one else has—walked out with the highest score we’ve ever seen anyone get on the exam, either the old or new version.

Sarah scored 116 out of 120, or 96.6% on the exam. Her secret? “I studied hard!”

She planned to take the exam in late June but some work matters arose that forced her to change her exam plans. She took the extra time to study.

She used several resources as she prepared: The CCDS Exam Study Guide, The Clinical Documentation Improvement Specialist’s Complete Training Guide, and The 2016 CDI Pocket Guide (all from HCPro) and the ACDIS/AHIMA joint brief “Guidelines for Achieving a Complaint Query Practice.”

“I took the practice test (in the CCDS Exam Study Guide) several times,” she said. “The first time was to establish a baseline to find my weaknesses, then I went back over those points exclusively to hone in on my deficiencies.”

Sarah is a clinical documentation specialist at Jackson Madison County General Hospital in Jackson, Tenn., and will celebrate three years in the role in September. Her background is in SICU, case management, and utilization review.

“I got into CDI when my husband transferred to Tennessee to go to grad school,” she told me. “I applied here for an opening in case management, and when I met with the recruiter she told me about the CDI opening. I knew someone at my former employer who was in CDI and who tried to get me into it.”

She is pleased she made the move to CDI.

“This is right up my alley,” Sarah says. “I like to try new things and this is challenging. Definitely the favorite thing I’ve done so far in my nursing career.

“It was a difficult test,” she said. “The biggest challenge was the wording on some of the questions. I went back and changed some answers, something I usually don’t do. I’m glad I did!”

Congratulations Sarah. The hard work paid off in a big way.

Weekend Reading:  Reconciliation processes

CCDS Exam Study Guide

CCDS Exam Study Guide

To support credible reporting, most successful CDI programs use a process known as reconciliation to confirm the accuracy of CDI data and metrics. Reconciliation of data entry at the time of final coding is necessary to capture the true outcome of the CDI process. Data entry that captures concurrent work should be reviewed at the closure of the case. A solid reconciliation process allows for final review of data entry for accuracy, including:

  • Baseline information
    • Includes DRG, severity of illness (SOI), and risk of mortality (ROM)
  • Query information
    • Impact and topic specificity
  • Physician response
    • Confirm query was answered
      • Agreed versus disagreed
    • Alignment of the final codes and DRG between concurrent CDI specialist and coder
      • Resulted in documentation in the medical record that allowed for accurate coding of the condition
    • Confirm who answered

Because the goal of a concurrent review is to ensure accurate clinical representation in the final coding, it is important for review and discussion to occur when the final codes and DRG do not match those identified by the CDI specialist. Reconciliation should include clear criteria guiding the process and outline communication pathways for further review and discussion of cases where there are questions or discrepancies between the expected or working CDI DRG and the coder’s final DRG. Developing and supporting this valuable process is vital to demonstrate program outcomes and success. The CDI team needs to understand this part of the process to fully comprehend the parameters of their role. The process for final coding and billing must be plainly visible to the documentation team and monitored for effectiveness. Ensuring that these processes are clearly known, executed, and monitored will guarantee program success.

Editor’s Note: This excerpt is from the CCDS Exam Study Guide, Third Edition, written by Fran Jurcak, MSN, RN, CCDS, and reviewed by Laurie L. Prescott, RN, MSN, CCDS, CDIP.

Tip: Manage and track physician advisors’ time to balance competing priorities

Reach out to your physician advisors, case managers, chief medical officers, vice president of medical affairs, president of the medical staff, and any other supportive individuals in your facility.

Physician advisors serve a variety of purposes beyond documentation improvement.

Physician advisors serve a variety of purposes beyond documentation improvement, including assisting case management, utilization review, quality, and coding departments, among other assignments, according to a recent benchmarking report and survey from ACDIS.

“The problem you run into is that the physician advisor role gets co-opted,” says Anthony F. Oliva, DO, MMM, FACPE, Vice President and Chief Medical Officer at JA Thomas/Nuance Communications, Inc., based in Burlington, Massachusetts.

As the physician advisor for a 15-hospital system, Erica E. Remer, MD, FACEP, CCDS, clinical documentation integrity advisor of University Hospitals in Cleveland, knows how difficult it can be to manage competing obligations.

“I work full-time in my system, and still it can feel overwhelming,” Remer says. “How can you accomplish everything and help your CDI program move forward if you have all these competing obligations?”

While CDI programs need to be flexible, keeping in mind the limited availability of the physician advisor, parameters should be set regarding how much of the advisor’s five to 10 hours per week should be spent on which tasks, says Louis Grujanac, DO, AHIMA ICD-10-CM/PCS trainer, an independent consultant based in the Chicago area.

“There’s five minutes here and five minutes there, and before you know it that physician advisor’s time is spent up and the CDI program has no additional room for larger education efforts, assessments, or growth analysis,” he says.

Tracking the physician advisor’s time should fall to the CDI program administrator or manager; the time tracking should weigh the advisor’s efforts against the larger needs of the program and ensure that individual physicians or CDI specialists aren’t monopolizing the advisor’s time with minutiae as opposed to bigger-picture educational or program improvement activities.