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Membership Update: ACDIS 2018 speaker proposal deadline extended

Join us in San Antonio!

Join us in San Antonio!

The Association of Clinical Documentation Improvement Specialists (ACDIS) is currently seeking speakers to present at the 2018 ACDIS 11th Annual Conference, to be held May 21-24 in San Antonio, Texas at the Henry B. Gonzalez Convention Center. The deadline for submissions has been extended due to the devastation brought by hurricanes Harvey and Irma. The new deadline is September 25. Click here to view and complete the speaker application.

We seek speakers to present on all aspects of clinical documentation improvement (CDI). Advanced CDI sessions geared for mature programs are particularly welcome and will receive additional consideration but the 2018 Conference Committee also seeks to meet the needs of those new to the profession and those at an intermediate level. Click here to meet the volunteers.

CDI and/or HIM/coding professionals typically present at ACDIS, but we also welcome practicing physicians, case management and quality personnel, healthcare auditors, lawyers, and other professionals with a tie to or an interest in CDI. Accepted speakers and co-presenters will have their admission fee waived.

Based on the learning needs identified by participants of the successful 2017 ACDIS Conference, several topics have emerged as areas of great interest within the ACDIS community, including two new tracks—outpatient CDI and pediatric CDI. Click here to read a full list of suggested sessions and tracks.

UnitedHealth Group, Inc. vs. the United States of America: The case for CDI, part 2

Brian-Murphy

ACDIS Director Brian Murphy

By Brian D. Murphy

In Part 1 of this series I introduced the developing story of UnitedHealth Group, Inc. vs. the United States of America, and my intent to write a series of articles on this civil fraud action. Why? Because I find this to be an incredibly interesting case with broad ramifications for CDI and coding departments.

So let’s review the basic at the facts of the case, starting with the who and when. [more]

Tip: The four E’s of staff education

journal banner summer

Brush up on some education tips and tricks!

by Amanda Southworth

Educating CDI staff and physicians alike can be a challenge. With busy schedules, resistant physicians, and a constantly changing healthcare environment, even the most seasoned educator can feel like pulling their hair out.

By keeping in mind four E’s, however, educating becomes a bit more manageable.

Efficient: Educational sessions should seek to get to the point quickly. With busy and fluid schedules, each educational session should have a focused point. Even if the timeframe incorporates a couple different subjects—say, clinical indicators and querying—each section still needs a point and direction. This will cut down on wasted time during your limited education space. [more]

Q&A: Receiving query responses from providers

Have CDI questions?

Have CDI questions?

Q: Our hospital is having a hard time getting our physicians to respond to queries, do you have any suggestions on how to get them to reply?

A: The most important thing is make sure the query is concise and contains clinical indicators from the record. You also want to use different methods of contacting the physician as well. Various points of contact include within the electronic health record, via e-mail, by phone, or by having your CDI team visit them on the floor. [more]

CDI Week: Only 11 days till 2017 kick-off

CDI Week committee

Meet the members of the 2017 CDI Week committee!

Every year, facilities across the country celebrate the efforts of their CDI teams for one week in September. Though ACDIS believes CDI professionals deserve accolades throughout the year, CDI Week is a time to pull out all the stops.

This year’s festivities take place September 18-22 and the theme is “The Wild West: New Frontiers for CDI.” Don’t forget to let ACDIS know what you’re planning for this year’s celebration and send plenty of pictures! We’d love to celebrate with you!

One change this year is the incorporation of the CDI Week Committee. As the ACDIS community and activities grow, ACDIS includes more of its members in planning festivities. [more]

Book excerpt: Defining clinical documentation and coding standards in the revenue cycle, integrating real-time auditing, part 2

Lamkin_Elizabeth

by Elizabeth Lamkin, MHA, ACHE

by Elizabeth Lamkin, MHA, ACHE

To reinforce formal documentation education provided to physicians and staff, open chart auditing and real-time education is needed. Effective facilities typically have a CDI program staffed with trained professionals to concurrently audit every open chart and query providers to obtain clarifications and additional documentation when needed.

Placing CDI staff on the clinical units to audit chart documentation in real time and personally interact with physicians and other clinical staff, often helps with education effectiveness as well. The CDI specialist can query the physician to explain why the documentation does not meet criteria or does not really tell the story of the patient’s condition.

[more]

Guest Post, Part 2: Where do we stand with clinical validation?

clinical validation poll(1)

According to an ACDIS poll, 70% conduct clinical validation reviews.

By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS

At the 2017 ACDIS conference in May, Nelly Leon Chisen, RHIA, director of coding and classification, the executive editor of the American Hospital Association’s (AHA) Coding Clinic provided clarification on the new Official Guidelines for Coding and Reporting, I.A.19 titled “Code Assignment and Clinical Criteria.” (Read last week’s post here.) At the meeting, Nelly explained the Guidelines intended to reaffirm long-standing advice that coding must be based on provider documentation, essentially that:

  • Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis, can “diagnose” the patient.
  • Clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider’s clinical judgement, or eliminate the need for provider documentation regarding the clinical significance of a patient’s medical condition.

[more]

Guest Post: Natural language processing and clinical documentation, part 2

CDI and technology

New technology heavily affects CDI and coding.

by Crystal R. Stalter, CPC, CCS-P, CDIP

Effect on coders

Once the patient is discharged, it is the coding team’s time to shine. If the hospitals’ providers and clinicians have an electronic health record (EHR) that uses natural language processing (NLP) technology, coding’s job becomes much easier. From the physicians/providers to the CDI specialists, NLP helps ensure documentation is robust, with conditions that have been queried when necessary and fully specified—producing a fully documented encounter by the time the chart crosses the coder’s desk.

[more]

Guest Post, Part 1: Where do we stand with clinical validation?

clinical validation queries

According to a recent survey, 44.88% send 5 or more clinical validation queries monthly.

By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS

The 2017 Official Guidelines for Coding and Reporting, effective October 1, 2016, contained a new, perplexing, and problematic section I.A.19 titled “Code Assignment and Clinical Criteria,” which states:

“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists.  The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

This has been incorrectly interpreted by some to mean that clinical validation of documented conditions is no longer required for code assignment on claims.

[more]

Note from the Associate Editorial Director: Join us on the ACDIS stage

Join us in San Antonio!

Join us in San Antonio!

by Melissa Varnavas

We started small, with just a handful of members. Their excitement, infectious. Soon ACDIS Director Brian Murphy organized a conference, nearly 200 people attended. There were just 13 speakers at that event.

Not a day goes by that we don’t marvel at the growth of the clinical documentation improvement profession. With the 10th annual ACDIS conference in the books and ACDIS’ 10th birthday coming up in October, we can’t help but see the association’s trajectory as an extension of that growth.

[more]