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News: CMS releases small practice MACRA factsheet

Take a closer look at hypotension documentation

In response to concerns raised by physicians, CMS released a MACRA and MIPS fact sheet for small practices.

Although physician practices may welcome some of the changes MACRA and MIPS will bring, other changes raised concerns that some physicians will be at a disadvantage under the new system. CMS’ regulatory impact analysis indicated that the quality and resource use components of MIPS would have a negative effect on many small, solo, and rural physician practices. In response to concerns raised by physicians, CMS released a MACRA and MIPS fact sheet for small practices.
The fact sheet, released May 13, clarifies that CMS based the regulatory analysis on 2014 data. At that time, most small and solo physician practices did not report performance data, CMS says, leaving a data gap that skewed calculations. In addition, the projections CMS included in the proposed rule were not calculated with the special accommodations designed to alleviate the projected negative impact and  allow greater flexibility for small practices. .

The fact sheet highlights some of the accommodations in MIPS and advanced alternative payment models (advanced APM).Physicians or physician groups who treat a low volume of Medicare patients, less than or equal to $10,000 in Medicare charges and less than or equal to 100 Medicare patients, are excluded from MIPS payment adjustments.

Small and solo physician practices will also be able to take advantage of group reporting under MIPS by joining virtual groups, a concept CMS currently seeks feedback on, which could leverage technology and possibly be  available by the second year of MIPS.

CMS will allow physicians to adjust their MIPS score based on the availability of applicable measures in a performance category. If there are not enough measures that apply to a physician in a category, CMS would not include that category in his or her MIPS score. The weights of other MIPS categories would be adjusted to make up the difference.

MIPS includes adjustments to reduce the burden of reporting measures, according to the fact sheet. Providers will be able to report quality, advancing care information, and clinical practice improvement activities through a single reporting mechanism, and they can earn bonus points through additional reporting or participation in an APM.

CMS invites physicians in small, solo, or rural practices to submit comments. Comments will be accepted until June 27.

Editor’s note: This article was originally published in Physician Practice Insider.

ACDIS Update: Upcoming CDI webcasts

EHRs alone don't solve documentation problems.

Stay in the know with this list of our upcoming shows.

The month of June is jam-packed with CDI webcasts. Stay in the know with this list of our upcoming shows.

How CDI Professionals Can Influence Patient Care with CMS HCCs

June 8, 2016, 1 p.m. EDT

Sponsored by Nuance


Risk adjustment is a critical component of value-based and alternate payment models. It promotes fair payments within these models and equitable measurement of quality and cost outcome measures across care settings. Precise clinical documentation that captures patients’ true disease burden across the care continuum – including the outpatient setting – is essential to quality patient care delivery and optimizing risk adjusted payment methodologies, such as, the Centers for Medicare and Medicaid Services’ (CMS) Hierarchical Condition Category (HCC). This session will show how one health system’s successful implementation of an outpatient CDI program using CMS HCCs resulted in improved risk scores, quality patient care, and enhanced financial outcomes with CMS HCCs.

Presented by Lenna Lizberg, BSN and Angela Carmichael, MBA, RHIA, CDIP, CCS, CCS-P, CRC. 


ACDIS Website Demo

June 16, 2016,


You may have noticed that the ACDIS website looks a little different nowadays. And there are a ton of new features that you may not be aware of. If you currently a member of ACDIS, or considering becoming one, we invite you to join us for a complimentary 30-minute webcast on June 16, 1 p.m. ET, detailing the features of our redesigned ACDIS website and the variety of benefits available with an ACDIS membership.

This webcast will be available for free on the ACDIS site following the live demo, so don’t worry if you cannot attend.

Presented by Brian Murphy, Melissa Varnavas, Penny Richards, and Katy Rushlau.

Expansion of Clinical Documentation Improvement to Outpatient and Physician Services: A Growing Trend

June 21, 2016, 1 p.m. EDT

Sponsored by 3M


As patient volume shifts from inpatient to outpatient services at healthcare provider organizations, attention to Clinical Documentation Improvement (CDI) is more crucial than ever.  A traditional inpatient CDI program focuses on physician documentation with a CDI Specialist concurrently reviewing documentation for additional complications and comorbidities to improve reimbursement while reducing bill-holds due to waiting for query responses.  With outpatient and physician services revenue cycle, additional diagnoses don’t necessarily mean additional payment.  CDI in these areas focus more on the inefficiencies that inadequate documentation creates in the revenue cycle, most frequently around medical necessity.

This webinar will provide insight into the outpatient CDI market and provide understanding of what your peers are doing, based on an ACDIS Outpatient CDI Survey.  We will review best-practice solutions for initializing an outpatient and physician services CDI program, as well as recommendations for enhancing an existing program.

Presented by Lisa A. Lanier, BS, CCS, AHIMA-Approved ICD-10-CM/PCS Trainer and Deborah Squatriglia, BSN, MS, MBA, CDIP.

A Note from the Associate Editorial Director: ACDIS publishes new physician advisor survey

Melissa Varnavas

Melissa Varnavas

It’s been four years since ACDIS asked its members to offer up their thoughts about the role of the physician advisor in clinical documentation improvement efforts. In those four years, much in the CDI world has changed but one thing hasn’t—CDI programs still say the role of the physician advisor needs to be better defined to be effective, according to a recently released survey and benchmarking report sponsored by Nuance.

“If there’s anything this survey data shows, it’s that physician advisors need to be trained and that many may need to be retrained,” says Louis Grujanac, MD, a Chicago-based independent consultant.

Well, that and the fact that we need more consistent job descriptions for our CDI physician advisors across the country and to hold those physician advisors more accountable to outcomes associated with those roles. In many instances, CDI specialist respondents indicated that their physician advisor was successful due to the fact that he or she was visible and accessible but later indicated there wasn’t any assessment plan in place or set of expectations for their physician advisor. Of course, it may be that those working principally to concurrently review inpatient medical records simply aren’t privy to information related to the details of their physician advisor’s position but more likely that such details simply do not exist.

So, I have a favor to ask of readers/ACDIS members—if you have a job description for your CDI physician advisor or an evaluation checklist for the role please consider sharing it with fellow members in the new resources section of the website. The more we share, the more we learn, and the better our programs all become.

Conference Special Update: Farewell from the ACDIS Director

Have a story about your trip home from ACDIS 2015? Share with us in the comments below!

Have a safe trip home, everyone!

The biggest and best CDI event of the year took place this week—the 9th annual ACDIS Conference in Atlanta. We had more than 1900 attendees, a figure that included CDI specialists, managers, revenue cycle directors, HIM/coding professionals, physicians and physician advisors to CDI, and exhibitors and sponsors. This was once again our biggest conference yet. Our team at our home base in Danvers, Massachusetts spent the past 14 months preparing for the conference, and the last few weeks have truly been “crunch time” with late nights and the usual anxieties that come with an event of this magnitude. But now that the conference has come to a close, I believe all the hard work was worth it. For those who attended the event, I hope you found it so.

This year we added some new wrinkles, including a 5th breakout and four panel sessions. At the end of day 1 we featured a panel of four physicians with the latest updates on the newly released definitions of sepsis and septic shock (Sepsis-3). We hosted two panels with the ACDIS advisory board, who gave a look inside what we’ve been working on at ACDIS, including our newly revised ACDIS Code of Ethics. I am very pleased that we had a presenter from CMS, Chief Medical Officer from the Atlanta Regional Office Dr. Richard Wild, who kicked off with a day 1 session on Value Based Purchasing and the Transformation of Healthcare. Healthcare is changing before our eyes and CDI professionals are perfectly positioned to lead the way through this change, positioned as they are at the intersection of clinical medicine and coded data. And we had a dynamite day 2 keynote speaker, Vicki Hess, who brought energy and passion and actionable change management strategies like you’ve never seen.

As great as our educational sessions were, I most looked forward to meeting old friends, making new ones, and learning from them all. Networking is at the heart of the ACDIS conference and I’ve never been ashamed to admit that our members learn as much or more from each other as we can bring them with our publications and leadership. With the return of our popular conference app, the networking began before we arrived in Atlanta in our busy activity feed. It was awesome to see! We were in a great spot and there was much fun to be had after hours with a nearby CNN tour, a world-class aquarium, terrific restaurants, and much more.

If you were one of the 1900 attendees, thank you for helping us create such a successful event. Though the conference has come to a close, please continue to let us know how ACDIS can best serve you. I’m here to listen and learn.

Safe travels home, everyone, and thank you for making the 9th annual ACDIS conference the most successful event yet!

Conference Special Update: ACDIS honors Achievement Awards winners at annual conference


This year’s award winners.

The Association of Clinical Documentation Improvement Specialists (ACDIS) honored the nation’s top clinical documentation improvement professionals at its 9th annual conference in Atlanta, GA. On May 23rd ACDIS recognized Candace E. Blankenship, BSN, RN, MedStar Union Memorial Hospital, with the Rookie of the Year award; Susan E. Kohl, MD, Baylor University Medical Center at Dallas, with the Excellence in Provider Engagement award; Jessica M. Vaughn, RN, BSN, CCDS, Wake Forest Baptist Health, with the Recognition of CDI Professional Achievement award, and Karen M. DiMeglio, RN, MS, CCDS, CPC, Lifespan, as its 2016 CDI Professional of the Year.

ACDIS Director Brian Murphy presented the four awards in the general morning session to kick off the 9th annual conference. The awards were presented in front of an audience of more than 1,700 of their peers.

ACDIS recently revised, updated, and expanded its awards for 2016 to reflect the changes occurring in healthcare and the CDI profession in particular. The new Rookie of the Year award recognizes the rapid growth of the CDI profession by awarding an outstanding CDI professional on the job less than two years at the time of nomination. The new Excellence in Provider Engagement award recognizes a professional who has made measurable impacts engaging providers (physicians, nurses, and others) in the need for accurate and complete documentation in the health record. The Recognition of CDI Professional Achievement award recognizes a professional who has made outstanding achievements within his or her facility, and the CDI Professional of the Year award is ACDIS’ top honor, given to a CDI professional who has made significant contributions within his or her organization and on the broader CDI community.

“These four individuals represent the best the CDI profession has to offer,” said Murphy. “Their contributions to the profession in the past year are truly remarkable. All the great work hospitals and providers do cannot be measured without accurate and complete health information in the medical record, including a full accounting of each patients’ diagnoses, procedures, and treatments, and physicians’ medical decision-making and clinical indicators to support diagnosis and treatment. CDI professionals play a critical role in today’s environment of quality and accountability by ensuring that all of these critical data elements are present in the chart.”

To learn more about the ACDIS Achievement Awards, the annual ACDIS conference, or ACDIS membership, please visit

Conference Special Update: ACDIS 2016 kicks off with welcome reception

ACDIS Director Brian Murphy provided opening remarks.

ACDIS Director Brian Murphy provided opening remarks.

The energy coming from the 9th Annual ACDIS Conference could be felt long before entering the convention center. The sense of excitement buzzing amongst the nearly 2,000 attendees was evident as they made the long walk from the hotel to the exhibit hall to kick off this year’s event in Atlanta, GA at a welcome reception on Monday evening.

Upon arriving, the atmosphere could be likened to that of a high school reunion—old friends, who only see each other once in a while, hugging and reminiscing over drinks and light appetizers as if no time has passed. Those new to the group are welcomed with open arms and, within a matter of seconds, are exchanging stories and jovial laughs with their colleagues.

The camaraderie amongst this close-knit community of CDI professionals truly is second to none.

ACDIS Director, Brian Murphy, welcomed the group with a few remarks. “As great as our educational sessions are I’m most looking forward to meeting old friends, making new ones, and learning from them all,” said Murphy. “Networking is at the heart of the ACDIS conference and I’ve never been ashamed to admit that our members learn as much or more from each other as we can bring them with our publications and leadership.”


Deborah Neville, of Elsevier, spoke during the reception.

The well-attended reception was sponsored by platinum sponsor, Elsevier, who also spoke to the group. “The industry is finally understanding the importance of the CDI profession,” said Deborah Neville, Director of Revenue Cycle, Coding, and Compliance at Elsevier. “I applaud each and every [attendee] for taking the time to be at this conference, to increase their knowledge and be able to improve patient care and healthcare overall.”

Murphy later announced that we are officially on the lookout for our 5,000th ACDIS member—we are only 10 away from reaching this exciting milestone! If you are not a part of this organization already, we invite YOU to sign up. Curious about membership benefits? Click here.

Conference Special Update: Speaker Q&A  


Sarah Mendiola, Esq., LPN, CPC

The importance of CDI involvement in denial management cannot be stressed enough. Join associate attorney, and returning ACDIS speaker, Sarah Mendiola, Esq., LPN, CPC tomorrow afternoon for her session, “Completing the Circle: The Importance of CDI Specialist Participation in the Denial Management Process.” We spoke with her about her experiences appealing claims that have been denied by CMS contractors, and what she hopes to bring to this year’s event. Join her for her session a 3:15 p.m. on Day 2, room C111.

Q: Tell me a little bit about why CDI specialists should get involved in the denial management process.

A: It is important for CDI specialists to understand what denials their organization is receiving, so that they can implement the appropriate safeguards on the front end to prevent them from reoccurring. Since the CDI team has the opportunity to review the documentation, typically before the claim is even billed, they have the opportunity to implement changes in practice to prevent future denials.

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

A: (Two) Midnights, Medicare, and Me! We will focus quite a bit on the 2-midnight rule. There was a lot of interest in the application of the rule when I presented at the conference last year, so I kept the format very similar to what we talked about then, and made this more of an updated presentation. Most of the presentation is focused on Medicare rules and documentation requirements, so we will talk about best practices for prevention, and opportunities for appeal if all else fails.

Q: Who should attend your presentation and why?

A: CDI specialists, physicians, nurses, and anyone else involved in chart review and/or patient status determinations.

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

A: There are so many! It really depends on the role of the CDI department in that facility. However, I think that it is most important for CDI professionals to be detail oriented and good educators. It is important to know your audience, to understand your physicians and practitioners, and be able to convey information in a way that is well received and will lead to practice changes when needed.

Q: What are you most looking forward to about this year’s conference? What is your favorite part of the conference?

A: I’m excited to be presenting! I always look forward to the educational sessions as well. The conference had so many great speakers last year and such a wide variety of topics—there is something of interest in each breakout time slot.

Conference Special Update: Pre-conference highlights best practices, emphasizes teamwork

Dr. Pinson is ready to teach CDI teams best practices in this pre-conference boot camp.

Dr. Pinson ready to to teach best practices for CDI teams.

Couldn’t make it to this year’s pre-conference sessions? ACDIS welcomed nearly 250 pre-con attendees who participated in one of our three courses.

Here’s a quick takeaway from Building a Best Practice CDI Team co-presented by Richard Pinson, MD, CCS and Cynthia Tang, RHIA, CCS. The co-creators of the beloved CDI Pocket Guide, created a working session focused on communication and collaboration among CDI specialists, coders, physicians, physician advisors, and other professionals. In fact, Pinson and Tang encouraged facilities to sign up their entire CDI team, and walked them through exercises and case studies.

Throughout the session, Pinson stressed the importance of understanding how your medical staff thinks and learns—and adjusting education methods accordingly. “A successful CDI team is based on engagement of medical staff obtained through effective communication,” said Pinson during the session. “For example, physicians often respond to education using evidence-based literature and consensus guidelines. By collaborating with your team, you will find the methods that work.”

Conference Special Update: Physician Advisor Boot Camp pearls of wisdom to share

IMG_5048During the Physician Advisor’s Role in CDI Boot Camp pre-conference event, James S. Kennedy, MD, CCS, CCDS, CDIP, president of CDIMD, Physician Champions based in Nashville, explained government payment methods including MS-DRGs, and offered a variety of idioms to help entertain and educate the nearly 100 attendees participating. I’ve known Dr. Kennedy a fairly long time and have come to look forward to hearing some of these. I thought I’d share a few with you.

“If the physician says it quacks, waddles, and flies south for the winter, the coder cannot say it’s a duck,” Kennedy says. “Maybe it’s a goose.

“You all know what MD really stands for, don’t you?” he asks the crowd. “My decision. I’m the doctor and it’s my decision as to how I treat this patient.”

Regarding the lack of provider involvement with establishing coding rules governed by the four cooperating parties: “If you’re not at the table, you’re on the menu. That’s why its important for the physician advisor to stay informed and, where comments are requested, [such as with the inpatient prospective payment system proposed rule and the AHA Coding Clinic for ICD-10-CM/PCS] offer the physician perspective.”

“A good lawyer knows the law. A better lawyer knows the judge and the jury. The best lawyer plays gold with the judge,” Kennedy says. “That’s why as the physician advisor you have to know the roles and be able to interpret them.”

“What’s my favorite radio station?” Kennedy asked. “Here in Atlanta there’s WAOK and WALR-FM in Greensville. But for physicians in your facility regarding the CDI program the only radio station they want to hear is WII-FM–what’s in it for me.”

Looking forward to hearing more from Trey La Charité, MD, medical director for clinical integration and physician advisor for clinical documentation integrity at the University of Tennessee Medical Center in Knoxville and the team from Vidant Health and Franciscan Alliance in North Carolina talk about how their physician advisors advanced the CDI program in innovative ways, tomorrow.

Sunday Reading: Start physician education with quality improvement

Trey La Charite, MD, at left, ACDIS Director Brian Murphy, center, and James S. Kennedy, MD, CCS, CDIP, play up the Tennessee state-theme during the 2013 ACDIS conference.

Trey La Charite, MD, at left, ACDIS Director Brian Murphy, center, and James S. Kennedy, MD, CCS, CDIP, play up the Tennessee state-theme during the 2013 ACDIS conference.

At their most elemental, CDI programs ensure diagnoses and treatments described by treating physicians accurately reflect the patients’ severity of illness using officially sanctioned International Classification of Diseases 10th Revision, Clinical Modification and Procedural Coding System (ICD-10-CM/PCS) terminology, and that such codes are appropriately captured and reported by the treating facility.

Most facilities only focus on this. In fact, most facilities, persuaded by the financial benefits of capturing additional complications or comorbidities (CC) and major complications or comorbidities (MCC) on the CMI of their biggest payer—Medicare—frequently limit the scope of CDI specialists’ reviews to this regard.

The physician advisor should push the facility to expand CDI efforts beyond the scope of CC/MCC capture and fiscal return on investment not only for compliance considerations but also to help earn support from the overall medical staff. Many CDI programs have steered away from the term “improvement” in favor of the term “integrity.” Some suggest that the term “improvement” sets the hospital administration at odds with its physicians implying that physicians’ documentation needs to “improve.” Others imply that for most medical staff, the term evokes a financial connotation—that CDI is about “improving” the facility’s finances over all else.

Whether your program uses the term “improvement,” “integrity,” or some other title, the underlying concern is to address the inherent “value” of CDI efforts in improving a whole host of hospital and patient outcomes. Additionally, the physician advisor needs to assure the medical staff that there is nothing illicit in routine interrogations of the medical record to ensure accuracy. Remember that CMS states:

“We do not believe there is anything inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.”

While many CDI programs start out fiscally focused, the ultimate goal should be to help physicians craft a record that accurately reflects their patients’ illness—to make their patients appear on paper as sick as they are in person. This documentation must be in the medical record because the pendulum in U.S. healthcare is swinging, and in many case has already swung, from a quantity-driven system to a quality-driven one.

If routinely practiced, CDI efforts improve patient outcomes—simply put better documentation improves the dialogue between physicians. Sadly, most physician discussion of a patient’s care, isn’t a face-to-face—it is the information contained in the medical record that allows one physician to quickly determine what care has been provided for what diagnoses thus far and which conditions he/she needs to monitor and care for.

As an example, try to remember the worst “code blue” situation you were ever involved in during your residency training or recent practice experience.  When you reviewed the chart at that critical moment, was there anything useful in it that could have helped you address that patient’s immediate needs any better?  There is nothing more frustrating or unsettling than to examine the chart of an acutely decompensating patient who has been in your facility for two weeks yet there is no useful information to be found.

Editor’s Note: This excerpt came from the Physician Advisor’s Guide to Clinical Documentation Improvement.