RSSRecent Articles

Conference Special Update: Thank you to our staff!

ACDIS and HCPro staff

ACDIS and HCPro staff

The office will officially close at the end of the day today as more than 30 members of our HCPro and BLR teammates make their way to the airport to support the ACDIS community during the largest conference we have ever conducted—with more than 1,500 paid attendees, 40 exhibitors, hundreds of exhibitor attendees, and more than 100 speakers and presenters.

The core ACDIS team is supported by dozens of people with innumerable talents that, when put together, produce the thriving conference we will experience in Atlanta. We hope you’ll join us in thanking our HCPro/BLR staff members who make the conference possible.

While it would be near impossible to name every single person who contributed in some way, we’re going to give it our best shot:

Shannon Storella, Kathy Wilson, Wendy Walsh, Maggie Gagnon, and the entire events team: Shannon is our fearless leader throughout the conference, from the planning stages to the live event. She keeps us all in line and helps the event run as smoothly as possible.

Kathy does an amazing job holding the entire event together working between the various departments as well as with the hotel staff and conference center management to ensure everything stays inline. The conference wouldn’t be as successful (or fun) without her!

Our conference presenters have gotten to know Wendy Walsh (or W2, as she sometimes signs her emails) very well over the past six to eight months. She is our conference producer extraordinaire, helping guide the speakers from the planning stages of their presentations through to execution at the actual conference. She keeps track of speakers’ presentations, makes sure their travel arrangements are set, ensures their presentations met ANCC continuing education requirements, and a host of other tasks required to keep the sessions full of quality information. Not to mention, she helps prepare our room moderators to produce the best session experience possible.

Maggie did a fantastic job both behind the scenes leading up to the conference and throughout the conference to generally ensure that the entire event ran smoothly.

Jess Carbone: Jess is the main person behind our ACDIS conference App, and worked tirelessly with the App developer throughout the year to improve functionality, add messaging, uploading materials, and training the rest of the ACDIS staff on how to use the App. We love seeing the attendees interact through the app and post updates from the sessions, and it would not be possible without all of Jess’s hard work!

Steven Andrews, Sharme Brodie, Katy Rushlau, Amanda Tyler, Laurie Prescott, Delaney Rebernik, and Rebecca Hendren: These amazing folks will be our room moderators for our five session tracks, making sure the sessions ran as smoothly as possible. They’ll let you know where the bathrooms are, ask you to silence your cell phones, and remind you to use the microphones to ask your questions at the close of the session. They will keep the rest of the conference group updated via the App on interesting quotes and tid-bits from each presentation as well. Special shout out to Laurie and Sharme, who will also be teaching our CDI for Quality Pre-Conference Boot Camp.

Sheila McGrath, David Horvath, Melissa Varnavas, Penny Richards, Rachel Dicker, Chris Driscoll, and everyone in the ACDIS booth: These hard-working folks will be available to explain the various books, pocket guides, newsletters, and other products available to help CDI programs train their staff and grow. In between sessions, the booth will be open to attendees wanting to make a purchase or ask a question, and they will be ready and eager to help.

Mary Ann Genovese, Jennifer Hollis, and the rest of our exhibit hall support staff: These folks do a great job working with exhibitors and organizing floor plans, and assisting and directing attendees during the conference.

Melissa Ketelson, Shannon McCall, Dave Garvey, and our registration folks: Thank you for making the registration process run so smoothly, and for answering attendee’s questions, fixing or replacing badges, and providing support throughout the conference.

And, finally, our operations manager and staff Matt Sharpe and Mike Mirabello, who make sure all our shipments arrived on time. You guys do not get enough credit for the incredible work you do—a total of 14 pallets, 378 pieces, and 7,474 pounds left the ACDIS office and it would not have been possible without you!

The list goes on, and surely we’ve still left off a few names! It truly does take a village, and it’s important to recognize the remarkable team behind the faces you know as ACDIS. The conference wouldn’t be what it is without the effort of each and every person on this team.


Weekend Reading: Components of a compliant query

CCDS Exam Study Guide

CCDS Exam Study Guide

A query should include the clinical indicators however it should not indicate the outcome of reimbursement or even quality scores. The goal is accurate and compliant documentation. With accuracy as the goal, there are times when the query will generate improved reimbursement and quality scores, and other times when they will lower reimbursement and quality scores. When communicating the reason for a query, the CDI specialist should speak to the accuracy of the record over reimbursement. Thus, CDI specialists do not want to create leading queries or queries that are not supported by the clinical elements in the health record.

Compliant queries should also include patient identifiers, ensuring that the correct patient is being considered. Queries should also include the name and contact information of the person originating the query. This provides the physician an opportunity to contact the CDI specialist to clarify the query or query process.

Here are the components of a compliant query:

  • Patient name
  • Admit date
  • Account number
  • Name and contact information of individual initiating the query
  • Clinical indicators that support the query
  • Statement or question of the issue

An example of a compliant query joint ACDIS/AHIMA query practice brief, Guidelines for Achieving a Compliant Query Practice, is for clarification of specificity of a diagnosis. This type of query would be appropriate for when documentation of the condition has already been provided but greater specificity is needed for accurate code assignment.

Can the etiology of the patient’s pneumonia be further specified? It is noted in the admitting history and physical examination this obtunded patient had a history of nausea and vomiting prior to admission to the hospital and is treated with clindamycin for Right lower lobe pneumonia. Based on the above, can the etiology of the pneumonia be further specified? If so, please document the type/etiology of the pneumonia in the progress notes.

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.

Conference Special Update: #TBT ACDIS through the years

We are just days away from the ACDIS conference, and a few of us at the ACDIS office are feeling a bit nostalgic. Check out these photos from the past nine conferences. We can’t wait for new memories in Atlanta!

ACDIS Through the Years by Slidely Photo Gallery

Conference Update: Speaker Q&A on creating a successful coding/CDI marriage

Diana Ortiz, RN

Diana Ortiz, RN

We are only two days until the core ACDIS team boards a Delta flight from Boston to Atlanta for the 2016 ACDIS conference! We cannot wait to connect with all of your nearly 2,000 attendees!

If you need assistance prior to the event please call our customer service team for assistance 877-727-1728. We will have customer service folks onsite and our registration team will be ready to assist you in the conference hall as well.

To view the full agenda and details, download the conference brochure, and check out the amazing features in the ACDIS 2016 Conference App. You can create your own itinerary, download materials, take notes, and even set event reminders all within the program.

As you put the finishing touches on your itinerary, take a look at what Diana Ortiz, RN, co-presenter with Kaycie Wood, MSHCM, RHIA, CCS, on “The Honeymoon Phase Is Over: Why Building a Collaborative Marriage Is the Key to Coding and CDI Success,” had to say in previewing her session with us. Join her next Wednesday in room C113, Level 1 at 1:30 p.m. for her presentation.

Q: Tell me a little bit about why building an effective relationship between CDI and coding is key to success?

A: Whenever you have two professional departments working together in absolute synergy, success is inevitable. This holds true for coding and CDI. By building, maintaining, and investing in this relationship here at [my facility] Ochsner Health System, we are seeing the results of our shared efforts.

Q: What are three things attendees can expect from your session?

A: Attendees can expect to learn more about coding and CDI shared processes, ways to successfully manage these processes, and ways to report out and hold each other accountable.

Q: Who should attend your presentation and why?

A: Coding and CDI leaders, because keeping both coding and CDI teams engaged and respectful of each other’s viewpoints is truly the key to both departments success. Hopefully, we can share ideas and inspire others as to how to successfully accomplish this.

Q: What do you think is the most important quality for a CDI professional to have?

A: I think the most important quality is an inherent ability to care about details and balance that care in the face of challenging daily changes.

Q: What are you most looking forward to about this year’s conference?

A: Listening to the speakers as well as the Q&A that follows each session, leaves me feeling refreshed and inspired with new ideas

Conference Special Update: Panel sessions cover CDI ethics, ICD-10 education, ACDIS advancements, and the new Sepsis-3 criteria

Oscar selfie at one of last year's conference panel sessions.

Oscar selfie at one of last year’s conference panel sessions.

We will be offering four panel sessions (three conference sessions and one special session) at this year’s annual conference. Each session offers audience members an opportunity to engage in a live discussion with CDI experts from a variety of professional backgrounds and experiences. The panels will be led by ACDIS Advisory Board members, who will help facilitate the discussions.

CDI Ethics: This roundtable discussion, which explores the ins and outs of the newly revised ACDIS Code of Ethics with practical discussion on real-life ethical scenarios from the field. The panelists include members of the ACDIS Advisory Board: Anny Yuen, RHIA, CCS, CCDS, CDIP; Judy Schade, RN, MSN, CCM, CCDS; Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP; Mark LeBlanc, RN, MBA, CCDS; Michelle McCormack, RN, BSN, CCDS, CRCR; and Wendy Clesi, RN, CCDS.

Physician Panel Diagnosis and Assessment of ICD-10: The second panel will explore how to best communicate with and educate your medical staff regarding coding and documentation in ICD-10. The panelists include several specialty-focused physicians including: Adriane Martin, DO, FACOS; Garry Huff, MD, CCS, CCDS; George Wood, MD; James Fee, MD, CCS, CCDS; and John Alexander, Jr., MD, MBA.

ACDIS Advisory Board Updates and CDI Issues: The third panel session highlights ongoing efforts of the ACDIS Advisory Board and review recent industry thought leadership and position statements released by the board. The group will also provide an extended opportunity for attendees to ask general questions about CDI efforts and the state of the profession. Join Anny Yuen, RHIA, CCS, CCDS, CDIP; Cheryl Ericson, MS, RN, CCDS, CDIP; James Fee, MD, CCS, CCDS; Paul Evans, RHIA, CCDS, CCS-P; Robin Jones, RN, BSN, CCDS, MHA/Ed; Tamara Hicks, RN, BSN, MHA, CCS, CCDS, ACM; and Wendy DeVreugd, RN, BSN, PHN, FNP, CCDS, MBA.

Last, on Tuesday May 24 at 4:30 p.m., join Sam Antonios, MD, FACP, FHM, CCDS; James Fee, MD, CCS, CCDS; James Kennedy, MD, CCS, CCDS, CDIP; and Richard Pinson, MD, FACP, CCS, as they discuss the newly released “Sepsis-3″ definition and criteria including the evolution of the term “sepsis” in clinical, administrative, and abstraction databases. This session will define how to use the term sepsis in these environments and offer strategies for coping with the new definition.

Conference Special Update: The app is back


The app is back for the 2016 conference!

Guess who’s back, back again. The app is back, tell a friend.

If you don’t understand this reference, that’s okay.

But in all seriousness, the ACDIS Conference App is back for the 2016 event! Attendees—you should have received a notification with your login information and download instructions. This post is meant to overview some of the App features, for those of you who are new to the App, as well as an introduction to some new tools.

The conference App will essentially be your lifeline for all things ACDIS 2016. Within it, you’ll find:

  • The detailed agenda
  • Full list of speakers
  • Sponsors exhibitors
  • Interactive map of the exhibit hall and conference spaces

The agenda tab allows you to add sessions to your personal agenda (labeled “My Agenda”), making it easy for you to keep track of which sessions you plan on attending and corresponding locations. By clicking on the session within the agenda, you will be brought to a page with a brief description of the session topic and speaker. There is also a link to that session’s materials, so you can access the slides before, during, and after the conference right from your phone.

Please note—for iPhone users, the slides will automatically pop up on your screen without leaving the App. However, Androids and other smartphones may need to download the slides to your phone, which can then be viewed as a PDF. We recommend testing this before the sessions begin.

This year, we’ve added a polling function to the App. This will allow our speakers to poll the audience during their sessions, and attendees can answer directly from the App. For those sessions that have a poll, a separate tab will appear at the top of that session’s page (next to the regular “details” and “activities” buttons). Don’t worry—ACDIS staff will walk through the polling process during each presentation.

You’ll also find some features that we’ll be using throughout the conference and beyond. There’s a newsfeed (the “activity feed”) where you can post “status” or updates. Feel free to post pictures, tag your fellow attendees, or include your location. We strongly encourage attendees to use the App to check into sessions and to share any take home tips they might be learning from a given speaker in a particular session.

The full list of attendees will allow you to network with and “follow” one another, much like Twitter or Facebook (don’t worry, we do not provide any contact information—only your name, credentials, and facility). This will be a great addition for those looking to catch up with old friends, meet up with others from their state networking group, or continue networking with those you connect with during the conference.

Our photo feed houses all of the photos uploaded into the news feed as well.

The App leaderboard awards “badges” for different App activities, such as updating a status, sharing your location, or uploading a photo. Each activity “badge” earns you points, which are tallied and displayed on the leaderboard. At the end of the conference, the attendee with the most points earns a special prize. Trust us, you don’t want to miss out!

To get started, simply download the App by visiting the Google Play Store or the Apple App store and searching ACDIS Conference. (If you downloaded the app last year, make sure to update it within the Google Play or Apple App store to access new features)

Once you’ve downloaded the app, there are a few things you should do:

  • Upload a photo of yourself, if you wish
  • Double check your profile information—your name, title, and facility or company—and edit if needed
  • Link your account to existing Facebook, Twitter, and LinkedIn accounts, allowing you to post status updates to multiple accounts at once

Next, play around with the App to familiarize yourself with the agenda and the calendar, make sure you know how to access the slides, and try updating a status or picture (or both!).

Remember—this App is intended for professional networking purposes. Please keep all posts and pictures appropriate!

We appreciate your cooperation, and we hope you are as excited as we are. Of course, you may have a few questions or concerns. If you need help we’ll have a special kiosk near the registration desk you can visit onsite, or you can message our App coordinator, Jessica Carbone, in the App. You can also call our customer service folks at 800-650-6787 or

News: Does Measuring Quality Really Ensure Patient Safety?

Melissa Varnavas

Melissa Varnavas

Healthcare lacks valid patient safety measures even though much—from reimbursement to tracking trends related to population health—rides on them. That’s what Peter Pronovost, MD, director of John Hopkins’ Armstrong Institute for Patient Safety and Quality, indicated in an opinion column “Toward a Safer Health Care System: The Critical Need to Improve Measurement,” in the May edition of the Journal of the American Medical Association (JAMA).

Pronovost and co-author Ashish Jha, MD, of the Harvard School of Public Health called on CMS to “define standards of what makes a good measure and set accuracy requirements before implementing measures in pay for performance and public reporting,” according to an article on the matter by HealthLeaders Media.

CMS intended to add new measures to its public reporting site Hospital Compare this month but delayed the launch to July, according to HealthLeaders. CMS isn’t the only place where healthcare data gets crunched and disseminated for public perusal. Private companies such as the Leapfrog Group, US News & World Reports, Healthgrades, and Consumer Reports, among others all offer rankings of hospitals and physicians.

CDI programs should avail themselves of this data and be aware of how their facility fares. Negative outcomes highlighted by such reports may show, as Pronovost and Jha intimate, poor data rather than poor patient care.

Q&A: Defining “repair”

Have a question that is troubling you and your team? Ask us!

Have a question that is troubling you and your team? Ask us!

Q: When I try to code Ileostomy takedown of the small bowel, with small bowel resection, and end-to-end anastomosis, I get to code 0DBB4ZZ.  However, I am not sure if this would this be a repair of the ileum, and therefore coded to 0DQB3ZZ? Coding Clinic notes code 0DBB4ZZ, but “repair” means “restore to previous function.” What is your advice for this scenario?

A: The Coding Clinic you are referring to reads:

The ileostomy takedown is coded as “Excision” because part of the ileum is removed, and the anas­tomosis is considered inherent to the surgery and not coded separately. The ICD-10-PCS Official Guide­lines for Coding and Reporting state “Procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part, are also not coded separately.” Assign the following ICD-10-PCS codes:

0DBB0ZZ Excision of ileum, open approach (for the ileostomy takedown)

0WQF0ZZ Repair abdominal wall, open approach (for parastomal hernia repair and stoma closure

You are absolutely correct; the definition of “repair” is “repairing to the extent possible, a body part to its normal anatomic structure and function.”

I do agree with you that the takedown does seem to fit the definition of a repair but, per the Coding Clinic advice, it is coded to the Root Operation of Excision. Until there is different guidance from Coding Clinic, this is how it would be coded.

I wish I could tell you that everything makes sense but, sometimes it does not.

Editor’s Note: Sharme Brodie, RN, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, CDI education specialist and CDI Boot Camp instructor for HCPro in Danvers, Massachusetts, answered this question. For information, contact her at For information regarding CDI Boot Camps offered by HCPro, visit


Conference Special Update: CCDS Exam Round Table

I'll never wear this pin but tomorrow I'll walk through the testing process.

Join CCDS Exam Coordinator Penny Richards and CCDS Exam Committee members Fran Jurcak and Laurie Prescott for an informational round table discussion about the Certified Clinical Documentation Specialist (CCDS) Exam at this year’s conference. We will discuss:

  • Exam overview
  • Eligibility requirements (both work and experience, and what does and does not meet requirements)
  • How to prepare and suggested resources
  • What to expect after the exam (whether you pass or do not)

And we’ll answer your questions.

This discussion will be held Tuesday, May 24, from 4:30 to 5:30 pm (after the close of regular sessions) in Room C102.

Conference Special Update: Why I attend the ACDIS Conference

The 2016 Conference will be held in Atlanta, GA.

The 2016 Conference will be held in Atlanta, GA

by Robin Deakins, RN, CCDS

It all started with my desire to attend the 2015 ACDIS conference to increase my knowledge of my profession and to see what others were doing. I took my request to my director to see if there were any funds available to help me cover the cost. She took it to the next level for approval and, in the process, it was decided that the hospital should send a group to go and learn as part of a “Lean Project.” (Read more about “Lean,” a quality management methodology, in the CDI Journal article, “Using “Lean” tools to reboot your CDI program.”)

So, a varied group of five staff members attended the conference in San Antonio, including a CDI specialist, a physician advisor, a CDI director, a financial director, and a coding supervisor. Having a diverse group was beneficial— it helped to have different viewpoints.

The entire group felt the conference was informative and interesting. We wanted to get to as many presentations as possible, so we met each morning to discuss who wanted to go to which session before dividing and conquering. That way we not only brought back a variety of viewpoint but also a lot more information to our hospital.

Shortly after returning to our facility, the group that attended the conference spearheaded an initiative to improve documentation in our medical records, using the ideas and information we discovered at the conference.

Then, in July, we launched a Rapid Process Improvement Week with a team of CDI specialists, coding professionals, physicians, quality managers, an HIM imaging coordinator, and others. We brainstormed, tested, and implemented ideas we found to be appropriate. During this time, we also implemented our electronic health record, so we had to change our priorities. Now that the EHR go-live is four months in, we are looking at revitalizing our plan.

We have had many successes, and also found things that didn’t really work. We will be looking to this year’s conference to gather additional ideas on how we can further improve our documentation practices.

I would highly recommend attending the ACDIS conference. It is money well spent and the information you can gather is invaluable!