Recent Articles
More questions from the mailbox
Hi everyone, a few members of the ACDIS advisory board weighed in on some questions sent in by our membership. I’m finally getting around to posting these here in CDI Blog. Keep checking back for updates!
Brian
Q: We have been educated by our coding staff not to use the residents’ notes except as a guideline. They have said that they can only code the record from the actual attending documentation. We try to get physicians to co-sign the resident notes, and sometimes they do and sometimes they don’t. Are other institutions coding right from residents’ notes, or are they also required to have the note cosigned?
Recap of fifth quarterly conference call
The fifth ACDIS quarterly conference call took place Thursday, November 20. That’s right, folks, it was our fifth! That means we’ve just passed our one year anniversary. Thanks to all of you who’ve helped to grow this organization and make it the success it’s been so far. We certainly look forward to more successful programs and events as we move quickly through the holidays and on to the New Year!
Speaking of successes, we had a lively discussion regarding AHIMA’s September release of its brief on how to conduct appropriate physician queries. As ACDIS Director Brian Murphy pointed out during the call, ACDIS submitted comments to AHIMA regarding the brief prior to its final publication. Many ACDIS members offered their opinions and helped to guide the final version.
The brief provides a framework description of what CDI specialists do in the field and also expresses the simple fact of the growth of physician queries as a process in today’s healthcare world, said Lynne Spryszak, RN, coordinator of Clinical Documentation Management Program at Alexian Brothers Medical Center, Elk Grove Village, IL. The brief “is still what I’d consider more or less incomplete but it is an improvement over the original” drafts of the document, she said.
It’s important to remember that the AHIMA brief primarily targets HIM professionals, said Robert S. Gold, MD, CEO, DCBA, Inc., in Atlanta. Although all panel members agreed there was much to be gleaned from the content of the final brief for CDI/CDM programs.
Questions from Brian’s Mailbox
Brian Murphy (our beloved ACDIS Director) routinely gets loads of e-mail and as much as he would love to be able to answer each message or question personally, the sheer volume can be overwhelming. So…he’s tossed a few questions my way and asked if I could address them.
The following are a few questions from his “in-box”:
Q: Should we document verbal queries in the record? Should we include paper queries in the record?
A: This is a matter for your facility to decide with collaboration from the CDS, HIM, and compliance departments. Let’s see what AHIMA had to say about this issue in the recently revised query brief Managing an Effective Query Process:
“Permanence and retention of the completed query form should be addressed in the healthcare entity’s policy, taking into account applicable state and quality improvement organization guidelines. The policy should specify whether the completed query will be a permanent part of the patient’s health record. If it will not be considered a permanent part of the patient’s health record (e.g., it might be considered a separate business record for the purpose of auditing, monitoring, and compliance), it is not subject to health record retention guidelines.”
So, there’s no hard and fast rule about this. Our facility does both. First, I’ll address the second part of the above question.
2009 ACDIS conference agenda finalized
Hi everyone, we recently finalized our 2009 ACDIS annual conference agenda. We’ll be mailing out a brochure towards the end of December, but I wanted to give you an early look at the offerings. Let me know if you have any questions (bmurphy@cdiassociation.com).
Update on certification, including prerequisites
General requirements
- Candidates applying for the examination will be required to list their documentation specialist experience. Applications may be audited to verify work history.
- Once a candidate has accumulated the necessary hours these do not expire.
- All work experience must be met by the application deadline.
- At least one year of documentation specialist experience or equivalent is required for each eligibility requirement.
Allowable resources
Examination takers for the CCDS will be allowed to bring the following two books with them into the examination:
- DRG Expert, published by Ingenix
- Standard drug reference guide
Books will be checked for additional pages or loose notes inserted or attached inside. These are not allowed to be brought into the exam. Test-takers may write hand-written notes into the books but not to an excessive degree.
Thanks, and please ask your questions here, or e-mail me at bmurphy@cdiassociation.com.
Brian
Clinical documentation specialists of Northeast Region hold first meeting at South Shore Hospital
Last Tuesday, Oct. 28, a group calling itself the Clinical Documentation Specialists of the Northeast Region held its first meeting at South Shore Hospital in Weymouth, MA. Gail Marini, Trish Nash, and Amy Trout of South Shore Hospital organized the meeting, and since ACDIS is located only an hour or so down the street (in Marblehead, MA), the three ladies were kind enough to invite myself to the meeting to speak about ACDIS and our upcoming certification exam.
For a first-ever meeting the turnout was great with some 33 clinical documentation specialists and a few HIM professionals gathered together in a conference room. [more]
ACDIS clinical documentation certification underway
Earlier this week (October 20 and 21), four members of the ACDIS-sponsored clincial documentation certification advisory board took a trip out to our home base here in Marblehead, Massachusetts, to begin the next and most important phase of our upcoming certification–writing test questions.
Under the guidance of a recognized national certification administration firm, Deborah Biskner, MBA, RHIA, CCS, a clinical documentation specialist from Port Huron Hospital in Michigan, Jill Brocker, RN, MSN, CCS, director of quality services for Indiana Heart Institute in Indianapolis, Mary Beth Brown, RN, BSN, manager of clinical documentation improvement/utilization review for Moses Cone Health System in Greensboro, North Carolina, and Mary Phelps, RHIA, CCS, CTR, CIC, senior associate for PricewaterhouseCoopers LLP in Charlotte, North Carolina, flew into Logan Airport to get started.
Continuing CDI Education: Where does it come from?
How many of you have read the Official Coding Guidelines for 2008? Anyone? Anyone??
Well, if you haven’t yet, why haven’t you? As CDI professionals I believe that it is our responsibility to make every effort to stay abreast of coding regulations and updates and how they affect our process.
The 3rd Quarter Coding Clinic updates were available earlier this month. It should be standard practice to read the updates and see if there’s something new you need to know.
ACDIS on the home front
If you’ve been a reader or a poster on CDI Talk you may have noticed that there have been several questions and replies about local ACDIS chapters or networking groups. No matter what area of the country you’re in, it’s clear that everyone is looking to connect with their “soul mates” in CDI.
If you’re an individual or a hospital looking to meet with your peers I can tell you how our group, Northern Illinois CDI Network, came into being. Maybe it’ll give you some ideas on how to get your own group going. [more]
Pressure Ulcer Coding and Staging
Does it sometimes seem like wound and pressure ulcer documentation is a movable feast? I’ve spent a lot of time scrutinizing wound documentation lately in anticipation of the new pressure ulcer codes being implemented October 1st and sometimes I can hardly believe what I’m seeing.
I’ve seen wound care flow sheets where vascular or diabetic ulcers are incorrectly documented with a stage (which should only be assigned to pressure ulcers) and I’ve seen pressure ulcers go from stage I to stage III or from stage III to stage I between one shift and the next. [more]