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News: National agency changes terminology associated with pressure ulcers

Sharme Brodie

Sharme Brodie

By Sharme Brodie, RN, CCDS

It seems change lurks near every corner we turn this year. While not every change results in significant shifts in CDI or coding practices, many still require our attention. In that regard, the National Pressure Ulcer Advisory Panel (NPUAP) announced two changes in the description of pressure ulcers recently.

The first, and relatively minor, change is a shift from Roman to Arabic numbers to identify the pressure wound stages to describe the extent or depth of the wound. Otherwise, the wound descriptions of stages 1-4, unstageable, and deep tissue injury, have not changed and are consistent with the ICD-10-CM code set. (For further information, related to the staging and wound descriptions visit

The second, and potentially more problematic, change regards NPUAP’s shift from the term “pressure ulcer” to the term “pressure injury” to more accurately describe damage to both intact and ulcerated skin. It describes a pressure injury as localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical device. The injury can present as intact skin or an open ulcer. These injuries result from intense and/or prolonged pressure or pressure combined with shear.

One reason behind the change is to alleviate the confusion between a stage 1 and deep tissue injury which are both used to describe an injury of intact skin, while the other stages describe open ulcers to the skin.

The term “suspected” has also been removed from the title of deep tissue injury.

ICD-10-CM includes phrases such as bed sore, decubitus ulcer, plaster ulcer, pressure area, and pressure sore as inclusion terms, meaning documentation of these terms will allow for the assignment of a code from the L89 code group for pressure ulcer. The term “pressure injury,” however is not listed.

The NPUAP is viewed as the leading authority related to pressure ulcer prevention and treatment. This panel provides education and research related to improved outcomes and prevention of pressure ulcers. Therefore, CDI professionals will likely soon begin to see providers using the term “pressure injury” in their documentation. The question is how will such documentation affect code assignment since there is no diagnosis code for “pressure injury.”

As CDI professionals we must now work with the issue that the expected professional terminology does not match the wording within the code set. This is much like how we struggled with the professional descriptions related to systolic and diastolic heart failure versus the more recent terminology of reduced or preserved ejection fraction. When providers use terms that were not evident within the code set we have to query for the needed specification. Fortunately, after a number of years a change was made with the most recent AHA Coding Clinic that allows more flexibility related to the coding of heart failure.

In a communication with ACDIS Director Brian Murphy, NPUAP’s Director of Meetings and Operations Jen Bank indicated that OASIS and CMS were notified of the change, stating, “This information is now in their hands, and as I’m sure you know it can take a while for government organizations to implement new changes.”

Yes, we all know these changes come slowly and likely more queries are in our future related to the terms used to describe pressure ulcers or pressure injuries.

We as CDI professionals must be aware of changes in terminology that are communicated to our providers and assist them in understanding the wording needed to obtain the most appropriate code. Pressure ulcers are important to capture as related to proper MS-DRG assignment, specific quality measures, and risk adjustment. We need to ensure these injuries are captured effectively.

Additionally, ACDIS submitted a question to AHA Coding Clinic for ICD-10-CM/PCS related to this change. We have asked that the term “pressure injury” be accepted as meaning pressure ulcer. Stay tuned as we await the answer. But in the meantime ensure you capture this diagnosis appropriately within the record and likely if your providers adopt this new terminology you will need to add a query for clarification.

Editor’s note: Brodie is a CDI education specialist for HCPro in Danvers, Massachusetts. Contact
her at For information regarding CDI Boot Camps offered by HCPro, visit

Note from the CCDS Coordinator: Onsite exam scoring available now

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

Onsite scoring enabled at remote testing centers.

by Penny Richards 

Live onsite scoring for the CCDS exam began again last Friday, April 15. This is welcome news for those waiting patiently for exam results and for those waiting to schedule their credentialing test until onsite scoring became available. The updated test includes questions on quality measures, ICD-10-CM/PCS concepts, and other items which reflect the changing expectations of those working in the CDI field.
The CCDS Exam Committee and AMP, the company which administers the exam, established 89 as the passing grade. This means candidates must get 89 of the 120 scored questions correct in order to pass the test, which translates to a passing percent of 74%.
The CCDS Exam Study Guide includes a practice test to help you get a feel for the actual exam. The CCDS Exam Study Guide remains the only approved exam resource. CDI Boot Camps are not designed as test preparatory classes, even though they are extremely valuable for foundational knowledge.
On a side note, there will be no on-site, paper-and-pencil CCDS examination following the Atlanta conference this year.

As always, feel free to drop me a note if you have questions.


Weekend Reading: Hierarchical condition classifications

The Physician Advisor's Guide to CDI.

The Physician Advisor’s Guide to CDI.

The Balanced Budget Act of 1997 required a new payment method to adjust Medicare+Choice payments to account for variations in per-capita costs based on health status and other demographic factors. Some of those demographic factors were:

  • Age
  • Sex
  • Medicaid status
  • Disability
  • Original reason for Medicare entitlement

So, the risk adjustment was based on the health risk of the patient. However, only 10% of Medicare+Choice payment rates were risk adjusted, and the other 90% were subject only to demographic adjustments. The Benefits Improvement and Protection Act of 2000 took this risk adjustment methodology to the next level and increased the payment ratio to:

  • 30% in 2004
  • 50% in 2005
  • 75% in 2006
  • 100% in 2007

In 2001, CMS developed a risk adjustment approach that balanced payment accuracy against the data burden for physician and outpatient hospital encounters. The result, in 2002, was the Hierarchical Condition Category (HCC) system.

The HCCs are diagnosis-code driven and include approximately 70 distinct disease groups derived from approximately 3,600 diagnosis codes which are mostly chronic but include some acute conditions, used primarily for outpatient services.

In 2003, President George W. Bush signed the Medicare Modernization Act, which created the Medicare Advantage program reliant solely on HCCs for payment. Medicare Advantage took the place of the previous Medicare+Choice program. Individuals who meet the criteria of the Medicare Advantage programs may have “special needs,” such as mental health concerns, long-term care, or end-stage renal disease (ESRD). The ranking of the diagnosis codes within the HCCs relates to the increased dollars received by the health plan to combat the increase in payment which providers of services receive for these high-cost cases within the healthcare system.

One of the goals of the Patient Protection and Affordable Care Act (ACA) signed into law by President Barack Obama in 2010 is to encourage provider efficiency. CMS defined “efficiency” as a ratio of observed-to-expected costs and outcomes for selected populations.

Essentially, the HCC is used to predict an individual beneficiary’s healthcare expenditures relative to the average beneficiary. These scores are used to adjust payments based on the health status (diagnostic data) and demographic characteristics (such as age and gender) of an enrollee. For example, if it costs 100 physicians $1,000 to treat a condition and it costs Dr. Kennedy $1,500 to treat a patient with that condition, Dr. Kennedy could be penalized when it comes time to adjust the payments based on risk assessments.

Furthermore, efficiency measurement metrics influencing reimbursement may be reported on CMS’ Physician Compare website.

Editor’s Note: This excerpt came from the Physician Advisor’s Guide to Clinical Documentation Improvement. Want to learn more about becoming an effective physician advisor? Consider attending our pre-conference session, Physician Advisor’s Role in CDI Boot Camp, at the annual ACDIS conference. Click here for more information.

Conference Update: Medical necessity reviews

Megan Buyrn

Megan Buyrn

The 2016 ACDIS conference takes place next month on May 23-26, in Atlanta. The ACDIS office is already buzzing with excitement as enter the final weeks of preparation. There is still plenty of time to sign up for the event. Remember, register a team of four and the fifth person attends for free! Call our customer service team for assistance 877-727-1728.

To view the full agenda and details, download the conference brochure. As you start to plan your itinerary, we’re we are interviewing a handful of speakers to give you a feel for the sessions. This week, we spoke with Megan Buyrn, BSN, RN, CCDS; Pence Livingston, BSN, RN; and MaryKate Rentschler, MBA, BSN, RN, who will present, “Medical Necessity Reviews: CDI impact on provider documentation.”

Q: Tell me a little but about the process that your facility took to improve documentation of medical necessity.  

Buyrn: Our emergency room providers decide the level of care at our facility, so we started with their documentation. We first conducted baseline audits, shared the results with the providers, and implemented other interventions, such as form revisions and tip cards. We then conducted continual follow-up audits with regular feedback and results for a two-year period. We expanded this process to include adult medicine, psychiatric, and pediatric inpatient areas.

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

MaryKate Rentschler

MaryKate Rentschler

Rentschler: First, we’ll help them identify opportunities to improve attending documentation of medical necessity for observation and inpatient hospitalization in order to decrease denial vulnerabilities. We will discuss how to develop a process for retrospective audits of observation, inpatient, and short stay ICU admissions. Finally, we will outline strategies to help improve physician compliance and hospital system processes through educational tools and strategic distribution of audit results.

Q: Who should attend your presentation and why?

Livingston: CDI specialists, physician advisors, utilization review staff, or anyone interested in medical necessity documentation for inpatient stays.

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

Buyrn: Here at Denver Health, flexibility is so very important. The scope of our skillset is broad and constantly shifting with the changing needs of the hospital and the healthcare rules and regulations. CDI specialists have to be open to learning new skills and finding ways to apply their newfound knowledge and educate others.

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

Rentschler: We look forward to hearing how other programs are succeeding, including innovative ways that CDI is affecting hospital processes.


Guest Post: Documentation requirements for observation services

Kimberly Anderwood Baker Hoy

Kimberly Anderwood Baker Hoy

by Kimberly Anderwood Hoy Baker, JD

Medicare covers observation care as an outpatient service under Part B payments. (Medicare reimburses different healthcare providers under different systems or parts—Part A for hospital payments, Part B for medical/doctor’s services, Part C which allows private insurers to provide Medicare benefits, and Part D for outpatient prescription drugs.) The Medicare Benefit Policy Manual defines observation as a:

“well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.”

Two key parts of this definition are the assessments and decision. Medicare mentions assessments and reassessments, presumably to emphasize the active period of care leading to the decision to discharge the patient or admit him or her as an inpatient. Once a decision has been made regarding the patient’s disposition, the care no longer meets this definition of observation, which becomes especially important if the decision has been made to discharge the patient to an alternate, lower level of care that is not available. In these cases, the continued care at a lower level, in lieu of discharge, does not meet the definition of observation because the decision to discharge the patient has been made.

Documentation requirements

Observation services can be ordered by physicians and other providers authorized by state law and hospital bylaws to admit patients or order outpatient tests. Physicians (e.g., emergency department [ED] physicians) who can order outpatient tests may order observation services even though they may not be authorized under hospital bylaws to admit patients for inpatient status. This allows some flexibility for placement of patients in observation. Note that standing orders for observation after surgery are not accepted. Orders for observation must be specific to the patient’s need for continued monitoring in response to clinical factors.

In addition to the order for observation, documentation must reflect that the patient is in the care of a physician. The Medicare Claims Processing Manual requires notes at the time of registration and discharge as well as other appropriate progress notes to be “timed, written, and signed by the physician.” The manual’s emphasis on the physician writing the progress notes aligns with the requirement for assessment and reassessment in the definition for observation. Assessing and reassessing a patient in observation ensures the patient is receiving active care and not simply a lower, custodial level of care.

Like other services covered by Medicare, observation must be reasonable and necessary or, in other words, medically necessary. The physician must document that he or she assessed patient risk to determine that the patient would benefit from observation services. Documentation should describe:

  • what risks are present that prevent the patient from being safely discharged home or to a lower level of care
  • how the patient would benefit from further observation at the hospital

Documentation of this assessment provides the basis of the medical necessity of the observation services.

Editor’s Note: This article was originally published in Patient Status Training Toolkit for Utilization Review.

Tip: Motivate providers with comparitive data

Jane Hoyt

Jane Hoyt

Are you looking for a quick and easy way to engage your providers? Homemade baked goods and gifts recognizing consistent high quality documentation are a viable option. But, while treats are great for some, the best strategy for motivating providers can, in many cases, be their own track records, says Jane Hoyt, BSN, RN, CCDS, CDIP, clinical documentation specialist at the University of Cincinnati Academic Health Center.

“Give them reports on their individual data and compare it to that of their own peers and specialty,” says Hoyt. “Then compare that specialty data to the same specialty in other hospitals within their cohort as well.”

These metrics can come from a number of places such as

  • Leapfrog
  • Physician/Hospital Compare
  • US World & News Reports
  • Consumer Reports

Increased understanding and a little healthy competition breeds sustainable interest and success for providers, hospitals, and CDI programs alike, Hoyt says.

Editor’s note: This tip is an excerpt from the forthcoming May/June edition of the CDI Journal. If you have a tip you’d like to share, post it in the comments section below and join the conversation! The CDI Journal is a bi-monthly online publication and an ACDIS membership benefit. If you’re not a member, join today and catch up on all the tested tips and tools from your CDI peers!



A Note from the ACDIS Editor: Thanks for getting social with us!

Katy Rushlau

Katy Rushlau

by Katy Rushlau

For those of you who follow ACDIS on social media—yes, we’re on Facebook, Twitter, and LinkedIn—you know that last week was a pretty big week for us. We launched our first ever daily giveaway, where we asked you, our followers, to like, share, and tag a friend in a post for a chance to win a copy of our Physician Advisor’s Guide to CDI. In total, we gave away eight books, had 155 shares, received 131 post likes and 60-plus page likes, and reached nearly 6,500 people.
What does all of that mean? To me, it speaks to the strength of the ACDIS community, and the power social media has in terms of bring us together. In this social media era, it’s important for groups like ours to take advantage of these settings to learn from one another, start discussions, and grow. While ACDIS provides numerous formal opportunities to network—the conference, local chapters, and CDI Talk come to mind—joining in on our various social platforms is a wonderful (and casual) way to connect, as well.
With every like, share, and comment, we’re doing something even more critical—boosting our reach. Last week, those nearly 6,500 people who saw our posts might not have seen them if it weren’t for all of you who participated in our contest. With the vitality of our presence on social media, ACDIS will be able to reach individuals throughout the country and world who may not have otherwise known we existed.
So, I encourage you, if you haven’t already, to please connect with us via social media. This is about so much more than a free book or a page like. It’s about reaching others who may benefit from our collective resources and knowledge so we can learn from each other. And to all of you who already do, thank you for strengthening our online voice and keeping our social media presence alive and well.


#ACDIS2016 #MyAtlantaPlan Coming to the conference?

Be sure to plan some “me” time for a great Atlanta experience!

The ACDIS conference is a whirlwind of great learning, networking and career-enhancing experiences. But it’s nice to take a break and get out to see a new city—and Atlanta has a lot to offer.

Here are some great places to visit that are close to the conference center:

CNN studios: Tours run daily from 9 a.m. to 5 p.m. Purchase tickets in advanced at

Centennial Olympic Park:  The park was the gathering spot for visitors and residents to enjoy during the 1996 Centennial Olympic Games. Be sure to catch the free “Fountain of Rings” show, which plays four times daily at 12:30 p.m., 3:30 p.m., 6:30 p.m., and 9 p.m.

World of Coca-Cola at Pemberton Place: You can

  • Taste more than 100 Cola-Cola beverages from around the globe in the Taste It! beverage lounge
  • Experience the 4-D Theater (3-D movie with moving seats)
  • Walk through Bottle Works and take home a FREE 8-ounce bottle of Coca‑Cola
  • Hug the 7-foot-tall and very friendly Coca‑Cola Polar Bear
  • See the world’s largest collection of Coca‑Cola memorabilia in Milestones of Refreshment

Open daily. Purchase tickets in advance at

College Football Hall of Fame: Archie Griffin, Bo Jackson, and Roger Stauback are just a few of the 963 college champions enshrined in these hallowed halls. Learn more at

Georgia Aquarium: A Beluga whale, African penguins, giant Pacific octopus, and weedy sea dragons all make this amazing aquarium their home. Purchase tickets in advance at

Center for Human and Civil Rights: This engaging cultural attraction connects the American civil rights movement to today’s global human rights movements. Learn more at

Ride MARTA: The Metropolitan Atlanta Rapid Transit Authority will help you get from here to there. You can even take MARTA from the airport! Click here for schedules, maps, fares and discount information:

Atlanta Braves: The Braves will play home games against the Milwaukee Brewers and Miami Marlins while ACDIS is in town. For tickets and team details, visit

Underground Atlanta: Explore a six-block, 12-acre, three-level shopping, restaurant and entertainment district. Learn more that

Want more ideas?

Guest Post: Sepsis 3.0 coding and documentation implications

Richard D. Pinson, MD, FACP, CCS

Richard D. Pinson, MD, FACP, CCS

by Richard D. Pinson, MD, FACP, CCS

Sepsis-3 states that “the term severe sepsis was redundant” indicating that sepsis without organ dysfunction does not exist. It appears that all cases of sepsis could now be considered severe sepsis having organ dysfunction; there would no longer be any cases of sepsis without organ dysfunction.

Unfortunately, the Sepsis-3 definitions, released in the Journal of American Medical Association (JAMA) in March, are inconsistent with the ICD-10-CM Official Guidelines for Coding and Reporting which do distinguish between sepsis without organ dysfunction and sepsis with organ dysfunction. Sepsis-3 also makes erroneous recommendations for the “primary” codes to be used pursuant to the new definitions in the United States, identifying code R65.20 for “sepsis” and R65.21 for “septic shock.”

In the United States we use ICD-10-CM, a modified version of the international ICD-10, and these codes are not “primary” sepsis codes at all. ICD-10-CM and the guidelines require a primary code for sepsis (e.g., A41.9, unspecified organism or B37.7, candida sepsis) be sequenced first, followed by code R65.20 for severe sepsis (sepsis with organ dysfunction) without septic shock if present, or R65.21 when septic shock is identified.

The guidelines and the ICD-10-CM classification itself do not require organ dysfunction be specified as “due to” sepsis (or severe sepsis stated) for assignment of R65.20 (severe sepsis), but having this documentation makes the connection indisputable. Based on Sepsis-3, it appears that acute organ dysfunction is intrinsically associated with sepsis because organ dysfunction is a necessary prerequisite for the diagnosis of sepsis.

According to Sepsis-3, sepsis cannot be a valid diagnosis without organ dysfunction caused by an infection. If organ failure (dysfunction) as defined by SOFA is documented in the record as well as sepsis, it therefore must be “associated with” sepsis.

Following the new Sepsis-3 definitions alone will leave the expectations and practices for national coding and reporting requirements unmet. The national healthcare database will become inconsistent, disrupting research, quality reporting, and national healthcare trends and planning. Even sepsis screening, early identification, and treatment that are the hallmarks of the Surviving Sepsis Campaign (SSC) may be impaired.

Of course ICD-10-CM and the guidelines can be modified on October 1 each year, and this may very well happen, and we may eventually see corresponding changes from SSC, and others. It appears likely that following both the old Sepsis-2 and new Sepsis-3 definitions may be necessary to accommodate these critical conflicts for now.

Until such time when clear and consistent guidance is available, providers and institutions must make serious decisions about diagnosis, documentation, sepsis management guidelines, quality reporting, and coding.

Editor’s Note: This article was originally published in JustCoding.  Richard D. Pinson, MD, FACP, CCS, a principal of HCQ Consulting, has more than 12 years of experience improving coding and clinical documentation practices and educating thousands of coders, documentation specialists, and physicians. He is a recognized CDI authority who co-authored the CDI Pocket Guide published by ACDIS, co-developed ACDIS’ CDI for the Clinician eLearning program for hospitals, and has written the monthly Coding Corner of the ACP Hospitalist magazine for over four years. Join him for the April 14 webinar, “New Sepsis Definition: Evolving Clinical, Documentation, and Coding Challenges.”  

A Note from the Associate Editorial Director: Physician advisors as part of the CDI team

Melissa Varnavas

Melissa Varnavas

It’s been five years since we surveyed the ACDIS members regarding the role physician advisors play in their day-to-day CDI efforts. Back in 2011, more than half of the 300 respondents said their CDI program employed a physician advisor. However, nearly 75% of those indicated their physician advisor worked less than five hours per week on clinical documentation-related matters, and 54% described their advisor as only either moderately effective or ineffective.

But that was then. Right?
With your help, we’ll answer that question and more in this year’s updated version of the survey. To participate in the survey click here.
“As the pendulum swings to a quality of care payment model you’ll see more emphasis on core measure and quality reporting and potentially more focus on physician advisor roles in CDI,” Trey La Charité, MD, physician advisor for CDI at the University of Tennessee at Knoxville, predicted in the 2011 report.
Since then, that shift toward quality payment models has come to fruition. Since then, value-based purchasing has come into play. Since then, CDI programs have started looking into their physicians’ evaluation and management coding. Since then, CDI shifted into outpatient efforts. Since then, some facilities have hired CDI teams comprised completely of physicians to perform the record review process.
And since then, La Charité, actually helped bring CDI education to physician advisors with the help of James S. Kennedy MD, CCS, CDIP, president of CDIMD Physician Champions in Smyrna, Tennessee, in the form of The Physician Advisor’s Guide to CDI, a nearly 200-page manual, and the ACDIS annual Physician Advisor’s Boot Camp pre-conference event.
We know how valuable physician engagement is to CDI. Now is your opportunity to tell us how your programs leverage your physician advisor’s efforts.