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What can you submit as CEUs for CCDS recertification?

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

You CAN use ACDIS conference CEUs for CCDS recertification!

Every now and again someone asks me a question that concerns me. Here is today’s troubling question:

Is it true that ACDIS conference CEUs cannot be used for my CCDS recertification?

The answer is NO! It is NOT true! It is FALSE!

Of course you can use ACDIS conference CEUs for CCDS recertification!

You have lots of options when it comes to recertification CEUs. You can earn 10 free CEUs each year for participating in the quarterly conference calls and completing the quizzes in the bi-monthly CDI Journal. You can use CEUs from any of the ACDIS CDI Boot Camps (online or live class programs).

There are many more options. We accept:

  • Nursing, AHIMA and AAPC CEUs CME credits for CDI-related training and education (ICD-10, clinical disease or diagnosis, coding, documentation improvement, diagnosis/pathology)
  • College course work relevant to healthcare/healthcare management, CDI or clinical coursework toward a degree
  • Presentations of CDI-related topics at seminars and speaking engagements—but not for presentations and training you deliver to coworkers

Here is a document that will help you know what you can submit for CCDS recertification. Be mindful of the restriction indicated on the recertification application.

Keep copies of the certificates you receive when you complete a training and submit them with your CCDS recertification application.

Editor’s Note: For more information, take a look at the recertification page on the ACDIS site. 

Guest Post: Look at the nuanced sepsis definitations before querying

Dr. Robert S. Gold

Dr. Robert S. Gold

By Robert S. Gold, MD

The incidence sepsis cases within the United States has quadrupled while the length of stay of these cases and the mortality has decreased. And Recovery Auditors have denied numerous claims because, at least in part, CDI staff queried to get sepsis DRGs when the patient didn’t have sepsis. While these professionals may have followed the letter of the law in terms of query compliance, they often do not follow the clinical letter of the law.

There’s sepsis and there’s alternative terms that are not sepsis.

Putting a patient on a “sepsis protocol” is not a diagnosis of sepsis. A sepsis protocol says the patient may have an infection and it may have advanced far enough to be serious and have systemic manifestations with increased risk of death, or it may turn out, after workup, that it wasn’t sepsis at all, or it may not be an infection at all.

A patient who has criteria of systemic inflammatory response syndrome (SIRS) has abnormalities in vital signs or abnormalities of lab tests. That alone is not sepsis under any circumstances—until it’s proven to be sepsis. Most patients do not exhibit the clinical indicators to even meet the criteria and, in many that did meet the criteria, the abnormalities had nothing to do with the infection.

Acute diverticulitis is acute diverticulitis. Acute otitis media is acute otitis media. Most bacterial infections have two of the four criteria of SIRS and most of these patients are not sick. Most patients seen in an emergency room with an infection and two of the four criteria that look like SIRS actually go home.

Using the term “sepsis syndrome” is another way of trying to get around truth. Once upon a time, “sepsis syndrome” actually meant sepsis; however it has evolved to be equivalent to SIRS and has no validity as a codable term at all until, and if, it is determined that the patient has actually has sepsis.  In fact, Coding Clinic even came to that conclusion in Second Quarter 2012 p. 21, and people who are assigning sepsis codes based on documentation of “sepsis syndrome” are taking quite a risk.

Editor’s note: Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician CDI programs, including needs for ICD-10. Contact him at 770-216-9691 or This article was originally published in the DCBA enewsletter CDI Talk.

Sunday Reading: Using the DRG Expert

The CDI Specialist's Training Guide

The CDI Specialist’s Training Guide

Most CDI specialists quickly learn the value of the DRG Expert® in their daily practice. The DRG Expert® typically can be found sitting on a CDI specialist’s desk to assist with “all questions DRG related.”

Although most CDI specialists have access to an encoder, CDI staff need to have a general understanding of how to use the manual and how to employ the logic for assigning a DRG code. An encoder automatically applies rationale to “group” the assigned codes and identify principal and secondary diagnoses and procedural codes to a specific DRG.

The DRG Expert®, published by Optum, is updated annually to reflect any changes mandated by CMS in its inpatient prospective payment system (IPPS) final rule. Optum has varied it’s publication over the years, but the principal structure, format, and use of the manual has remained fairly consistent.

The first section lists the DRGs numerically, from DRG 001, Heart Transplant or Implant of Heart Assist System with MCC, to DRG 999, Ungroupable. This list identifies which major diagnostic category (MDC) the DRG belongs in as well as the page number for the full listing.

For example, DRG 682, Renal Failure with MCC, is listed in MDC 11, Diseases and Disorders of the Kidney and Urinary Tract. When you go to the page listed, it identifies DRG 682, Renal Failure with MCC, and provides information pertaining to the geometric length of stay (GMLOS), the average length of stay (ALOS), and relative weight (RW) of the DRG.

The entry for DRG 682 within the DRG Expert® indicates that DRG 682, Renal Failure with an MCC, has a GMLOS of 4.9 days, an AMLOS of 6.5 days, and a RW of 1.5862. Below this is a list of codes and principal diagnoses that map to this DRG. For example, a principal diagnosis of tumor lysis syndrome, oliguria and anuria, or acute kidney failure with lesion of tubular necrosis will map to DRG 682 if an MCC is also present.

Next on this same page is DRG 683, Renal Failure with CC, and 684, Renal Failure without CC/MCC. The same principal diagnoses listed under DRG 682 apply to these DRGs as well. The presence or absence of CCs and MCCs determines the final DRG assignment.

DRG Expert® also lists DRGs by MDC so you can identify which DRGs fall into what category. For example, DRG 163, Major Chest Procedure with MCC, falls into a surgical DRG within MDC 4, Diseases and Disorders of the Respiratory System. Curious about what procedures would fall into the major chest procedures? Turn to the page listed for DRG 163 for the listing.

Editor’s Note: This excerpt was taken from the Online Materials in The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.

ICD-10 Tip of the Week: Support your colleagues

team02In an email to ACDIS last month, Teri Ryan, RN, BSN, MBA, CCDS, Clinical Documentation Quality Reviewer at Aurora Health Care sent along this throw-back from former U.S. Secretary of Defense Donald Rumsfeld. He said:

“There are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns – the ones we don’t know we don’t know. And … it is the latter category that tend to be the difficult ones.”

The same may be said of ICD-10-CM/PCS implementation, Ryan suggested. HIM, coding, and CDI professionals have studied the code set, learned about the documentation improvement opportunities, and understand what the code set is all about. These are the things we know.

Yet, in the coming days, weeks, and months CDI query rates may rise, coders retrospective queries increase, and the number of cases discharged not final billed could incrementally increase, too. These are the known unknowns.

There are many unknown unknowns, as Rumsfeld put it. Will software and CDI programs work correctly (take a look at the CDI Talk string to hear how others have been faring so far)? How will our claims processing go two or three more months down the line? What will ultimately happen with ICD-10-CM/PCS code updates following the three-plus year moratorium and how will the new code set affect MS-DRG assignment?

And yet, as ACDIS Director Brian Murphy put it in a special letter to ACDIS members on go-live day, “the day has finally arrived. After years of delay, ICD-10-CM/PCS implementation is here. Implementing it will be a challenge, but one we believe is worth the struggle.”

Murphy went on to acknowledge the vital role that CDI professionals play in the code sets’ role out and encouraged those working in the field to continue to share their stories, struggles, and successes with ACDIS.

ACDIS was founded on, and has grown from, the generosity of its members. Simple quotes, like the one above from Ryan, and tales from your CDI programs’ front lines, offer others insight, hope, positive feedback, and inspiration they can take back to their own facilities.

Karen Gray, RN, CCDS, from Salem Health System in Oregon, sent along some photos of her facility’s activities on go-live day. The team all wore matching “lifeguard” tee shirts, set out buckets of lifesaver candies, decorated balloon with ICD-10 themes, and even posted Halloween-themed ICD-10 messages. They had fortune cookies made with ICD-10 documentation tips and rounded the hospital floors to check-in with their physicians and make sure everything was going okay. The group really tried to embrace the day and keep it from being something scary, Gray explained.

To bring some Halloween-fun to the ICD-10-CM/PCS implementation process, the folks at Munson Healthcare in Cadillac, Michigan dressed as a code. You can see their photos on our Facebook page.

“We know the vital role you as CDI professionals play in ensuring your facility’s transition to the new code set, and trust that you’ll be successful in your endeavors,” Murphy wrote.

Please send us your photos, success stories, trouble areas, and any sample education materials or query templates your team may be developing to donate to the Forms & Tools Library.

“We’d love to hear from you and sharing experiences with your colleagues and members is a big part of what ACDIS is all about,” Murphy wrote.

TBT: Putting partisan politics aside, even in CDI

When you think of "politics" in terms of who gets what piece of the pie, the CDI profession may take on a larger role in the healthcare vision.

Unfortunately at many facilities, this national situation with partisan politics also plays out amongst the various healthcare silos.

Editor’s Note: In social media memes, Throw-back Thursday generally means sharing an old high school photo, something you likely wish had been left unpublished. Alternatively, we’ve flipped the theme around, going back into our archives to highlight some salient tid-bit worthy of second look. This week, we looked at an Associate Director’s Note in the Nov. 20, 2014 issue of CDI Strategies, “Putting partisan politics aside, even in CDI.”

Unfortunately at many facilities, this national situation with partisan politics also plays out amongst the various healthcare silos. Physicians balk at transitioning to electronic health records and ICD-10-CM/PCS implementation, coders cringe at what they perceive to be CDI infringement, and CDI specialists hailing from bedside care flinch when asked to curb their clinical involvement or expand their efforts beyond CC/MCC capture.

And yet, just like effective government, effective patient care (and the soon-to-come population management of that larger global healthcare) depends on the cohesive, cooperative efforts of these three critical branches—physicians, CDI specialists, and coders—to work together in solving healthcare’s documentation woes.

Where conflict does occur, CDI specialists need to take the high-ground and identify ways in which their acumen can help solve the problems of the communities they serve. That may mean reaching out to particularly troublesome physicians or digging into data to identify ways the CDI department can help coders solve a thorny ongoing documentation problem. It may mean reaching beyond the current scope of practice to identify documentation needs related hospital acquired conditions, mortality data, or denials management.

In working together to solve one-another’s most pressing needs we can help elevate not only the content of the medical record but actual patient care provided in facilities nationwide.

For additional insight consider reviewing the 2012 ACDIS conference presentation “How partnership with medical directors, clinical integration specialists, and coders impacts patient care,” or the 2010 ACDIS Conference presentation “The clinical/coding reconciliation process.”

The following related articles are available under the CDI Journal section of the ACDIS website:

Q&A: Seeing oliguric and non-oliguric renal failure in documentation  

Don't get overwhelmed! Just ask us for help! Leave your question in the comments section below.

Don’t get overwhelmed! Just ask us for help! Leave your question in the comments section below.

Q: I have seen documentation of oliguric renal failure and non-oliguric renal failure. What is the difference and does it impact coding?

A: We can define acute kidney injury (AKI) in terms of serum creatinine stages but we can also define it in terms of urinary output. Now the term “oliguric renal failure” is one we use where people have AKI but their urine output is less than normal.
Normal urine flow should be greater than a liter a day. If you have 500 cubic centimeters up to a normal amount of urine output in a day, then that’s what we call non-oliguric renal failure, because the patient is putting out urine. These people tend to have less injury to the kidney and have greater survival statistics and so forth.

Now if the patient’s urine flow is below 500 cc a day and this is in the face of adequate fluid replacement, then the patient is not making urine appropriately and we call those people oliguric. That indicates that the patient probably has a more severe expression of the AKI or the acute tubular necrosis.

Now if you get below 50 cc, we call that anuric. We don’t see that very often in AKI or acute renal failure but when we do, patients typically have massive necrosis and a lot of times these people have cortical necrosis. The whole surface of the kidney is ischemic. But you also can see it in bilateral urinary obstruction from tumors in the pelvis. Again, the typical AKI doesn’t produce anuria. But oliguric renal failure is not uncommon and providers try to catch people early and convert them from oliguric to non-oliguric. However, this only relates to urine flow and it really doesn’t change how you code it at all.

Editor’s Note: This article was originally published in JustCoding. Garry L. Huff, MD, CCS, CCDS, AHIMA-approved ICD-10-CM/PCS trainer and president of Huff DRG Review in Eads, Tennessee, answered this question on the HCPro webcast “Acute Kidney Injury: Use Case Studies to Improve Renal Coding, Querying.”

ACDIS announces CCDS Exam changes

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

ACDIS is making several changes to the Certified Clinical Documentation Specialist exam effective January 18, 2016.

ACDIS is making several changes to the Certified Clinical Documentation Specialist exam effective January 18, 2016. Candidates will have three hours to complete the exam, which will contain 140 questions.

What’s new on the exam?

  • ICD-10
    • ICD-10 related questions will replace ICD-9 related questions on the current exam. Please remember this is not a coding exam and code assignment is not required.
  • New quality section
    • An eighth section is being added to the exam. Impact of Reportable Diagnoses on Quality of Care will include 10 questions on topics such as:
      • Severity of illness/risk of mortality
      • Quality data
      • Quality metrics
      • Hospital Inpatient Quality Reporting Program
      • Hospital Value Based Purchasing
      • Patient Safety Indicator 90

Click this link to see a complete list of the eight exam sections and their content.

  • Delayed score results
    • Candidates taking the exam will not get their scores on site after completing the exam. The ACDIS CCDS Advisory Board and a team from Applied Measurement Professionals (AMP, the company that administers the exam) will meet to review the first few weeks of exam results and determine the passing score. We anticipate that instant on-site score results will resume by early March 2016.

Please email Penny Richards with your questions.

Sunday Reading: CDI role in capturing present on admission conditions

27438_mb320896_cdipocketguide_cover_265x265A present on admission (POA) indicator must be reported for all principal and secondary diagnoses and external cause of injury codes. This is required to identify complications of care.

The POA indicators are:

  • Y (Yes): Present at the time of inpatient admission
  • N (No): Not present at the time of inpatient admission
  • U (Unknown): Documentation is insufficient to determine if condition is present on admission (a query may be necessary)
  • W (Clinically undetermined): Provider is unable to clinically determine whether condition was present on admission or not
  • 1 (Unreported/not used): Exempt from POA reporting

A POA indicator of U (unknown) is equivalent to N (no), and W (clinically undetermined) is equivalent to Y (yes).

POA definition: Present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.

POA documentation. Medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission. The term “provider” means a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis.

CMS has no limitation on the time period during which a provider must identify or document that a condition was present on admission.

Editor’s Note: This excerpt was taken from the 2015 CDI Pocket Guide written by Richard D. Pinson, MD, FACP, CCS, and Cynthia L. Tang, RHIA, CCS. Pre-order the 2016 CDI Pocket Guide today. Click here for more information, or contact customer service at or 800-650-6787.

ICD-10 Tip of the Week: Establish an ICD-10 denial management team

Consider CDI collaboration with case management to target documentation concerns in the emergency department.

Create a group that will focus on ICD-10 denials that reports back to the steering committee.

As we look ahead to next year, and prepare for ongoing challenges in a post-implementation world, this is the time to establish an ICD-10 denial management team.

If your facility has a denial management team already, have them provide regular reports to the ICD-10 steering committee. If your facility doesn’t have a denial management team, create a group that will focus on ICD-10 denials that reports back to the steering committee. The group should include:

  • CDI
  • Billing
  • HIM
  • Patient financial services

The denials group should review payment and claims processes problems as they relate to the new code set. Discuss certain diagnoses or patterns, and use this information to go back and educate your CDI team, physicians, and coders.

As your facility continues ICD-10 integration, the steering committee should also determine the financial impact of ICD-10 on contracting and summarize overall expense and budget for the implementation project. This is a task that should be handled much further down the implementation road, but is something CDI and the ICD-10 steering committee should be aware of and start planning for now.

Editor’s Note: This post was compiled using a number of ACDIS resources. For more information, check out the following:

TBT: Involve your CDI team in medical necessity reviews

Go team! In coming posts you can learn more about the people who work behind the scenes to make ACDIS a success.

CDI can work together to tackle medical necessity reviews

Editor’s Note: In social media memes, Throw-back Thursday generally means sharing an old high school photo, something you likely wish had been left unpublished. Alternatively, we’ve flipped the theme around, going back into our archives to highlight some salient tid-bit worthy of second look. This week, we looked at “Five Ideas for Maximizing Your CDI Team’s Impact on RAC Preparedness,” a 2011 ACDIS White Paper, written by Lynne Spryszak, RN, CCDS, CPC-A.

If the current focus of your CDI program is DRG optimization, then your CDI specialists probably spend little time analyzing the record for documentation that substantiates the medical necessity of the inpatient stay. During the concurrent review process, many CDI specialists ask themselves why a patient is in the hospital, since the documentation and resources being used often do not appear to support inpatient services. If your utilization reviewers have no understanding of the documentation and coding requirements, you may indeed have records denied for lack of medical necessity.

A typical example is the patient who is admitted with chest pain. Two or three days go by as the physician orders and analyzes the results of the medical workup. On the day of discharge, the provider writes “chest pain due to angina versus GERD” (gastroesophageal reflux disease).

Upon admission, the initial note may have read “chest pain, rule out MI” (myocardial infarction), and based on this diagnosis the patient was admitted as an inpatient. A clinician may look at the test results and treatments and determine that the angina or GERD will be assigned as the final diagnosis. However, based on coding rules, the final principal diagnosis – that which determines the DRG—will be “chest pain,” which has been selected for both DRG validation and medical necessity reviews.

This is a good example of the difference between clinical interpretation and coding interpretation. The record must be analyzed from both perspectives to minimize medical necessity denials.