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Conference Update: Getting CDI involved in critical access hospitals


Debbie Mackaman, RHIA, CPCO, CCDS

There’s less than a month left to receive the early bird rate ($805 member, $905 non-member) for the . Don’t miss your chance to save! To view the conference brochure and agenda, click here.

As the countdown continues, we spoke with Debbie Mackaman, RHIA, CPCO, CCDS, regulatory specialist at HCPro in Danvers, Massachusetts, who will present, “Outside of the Box: CDI Programs in Critical Access Hospitals.”

Q: Why is it important for CDI professionals to get involved in the critical access hospital (CAH) setting?

A: A CDI professional in a CAH setting has to be able to expand their traditional skill set and wear many hats. Since a CAH is not paid under the MS-DRG for its inpatients, improving documentation takes on a new twist. It is not unusual for a CDI program in a CAH to expand into those outpatient areas with a regulatory focus. A CDI professional can be instrumental in not only improving documentation in the inpatient area to affect quality patient care but also in the ER and observation areas as a part of the transition from outpatient to inpatient status.

Q: How is your topic important for everyone regardless of professional background?

A: Thinking outside of the box in the CDI arena shows the value and versatility of the CDI professional. Some of the ideas that will be addressed during the session are not just for CAH CDI staff but could be used by all hospitals. The only true difference between a CAH and other hospitals is the payment methodology—cost versus pay-per-service. Adding value to a CDI program by thinking outside of the box should be a common theme for all hospitals. As a past compliance officer and current regulatory specialist, a broad range of staff need to understand the regulations that drive appropriate billing and payment. CDI staff can play a key role in guiding any hospital’s compliance efforts.

Q: As an RHIA, how does your perspective differ from other professionals performing the CDI role?

A: My HIM background provides the perspective of how the EHR elements and requirements all fit together. Solid documentation has always been a foundational element of the HIM profession. It is the documentation which helps to promote quality patient care and accurate coding, to support medical necessity of the services provided, and also to meet the various government regulations that all hospitals must abide by. HIM professionals have historically been liaisons across many department lines and have been instrumental in maintaining good working relationships with the medical staff. The HIM and CDI professions are intertwined—both are working towards the same goal just at different times in the course of care. We can learn a lot from each other by teaming up and sharing our expertise.

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

A: The ability to “speak the language” of the many different staff and healthcare professionals that CDI programs affect. Being “bilingual” in this way adds credibility to the CDI profession and increases job satisfaction.

Q: Why do you think attending the ACDIS conference is important?

A: Networking, sharing new ideas and solving old problems, growth personally and professionally.


Gold’s Gospel: Coma sense

Dr. Robert S. Gold

Dr. Robert S. Gold

By Robert S. Gold, MD

Someone recently stated that CMS says it’s okay to code metabolic encephalopathy when a diabetic patient has low glucose levels and comes in with hypoglycemic-induced confusion.

All patients with low sugars have alteration of mental state. They don’t all have encephalopathy. Specific definitions are hard to find. A reasonable definition might be:

“It is the condition arising due to very low blood sugar levels leading to deprivation of essential sugar and energy for the brain, which may lead to permanent damage to one or more areas of the brain if sustained for more than a few minutes.”

Cases are described where there might be coma due to hypoglycemia, induced by acidosis or by sugar energy deprivation (neuroglycopenia) to the neurons with cellular damage or death, development of choreic or hemi-ballistic movements, akinetic-rigid syndrome, or coma.

Symptoms like headache or confusion or bizarre behavior are all inherent to hypoglycemia and, when reversed by a Tootsie Roll, are not metabolic encephalopathy. Yet some people will latch onto this misinterpretation of a poorly presented position and metabolic encephalopathy coding will soar, leading to major dilution of the severity of this potentially deadly condition, just like happened to acute renal failure.

Diabetic coma is diabetic coma—it’s got a name and an ICD-10-CM code. It has several codes within the E08–E13 series, Exx.641, and it’s already an MCC. Non-diabetic patients can develop hypoglycemic coma (E15). This is a CC. These are the terms to use, not metabolic encephalopathy. All rules say that you use the most specific code for the patient’s condition—not the one that brings in the most Medicare dollars when it’s the wrong code to use.

Editor’s Note: This post was originally published in JustCoding.

Ask ACDIS: Creating Compliant Verbal Query Processes

Seems there's no end to questions about the difference between SIRS and sepsis. Here's a brief reminder from Dr. Gold.

Not all verbal interactions between the physician and the CDI specialist rise to the level of a verbal query.

Q: Can you clarify the expectations related to documenting the discussion between a physician and a CDI specialist when a query is done verbally. The 2013 ACDIS/AHIMA physician query practice brief Guidelines for Achieving a Compliant Query Practice expanded on the need to document this interaction and we’re wondering if our process is compliant.

We write out the query form and discuss it with the physician. If the physician agrees, he or she adds the detail into the medical record. On the completed form, we simply add a “V” or the words “verbal query.”

Do you have any additional advice? How do you recommend programs track verbal queries for compliance?

A: Not all verbal interactions between the physician and the CDI specialist rise to the level of a verbal query, says ACDIS Advisory Board member Anny P. Yuen, RHIA, CCS, CCDS, CDIP, director of ambulatory CDI at Enjoin. All CDI programs need to establish policies and procedures surrounding verbal queries and how they are tracked. All organizations should have a permanent record of verbal query language in order to demonstrate compliance and allow for adequate quality monitoring.

Such policies should follow guidance from ACDIS/AHIMA, agrees ACDIS Advisory Board member Judy Schade, RN, MSN, CCM, CCDS, CDI specialist at the Mayo Clinic Hospital in Arizona, who offers the following tips:

  1. Determine if the verbal discussion was educational or related to a documentation opportunity.
    1. If the CDI specialist presents the physician with specific clinical indicators, diagnostic results, interventions, and treatment plan related to a particular patient with an expected outcome then it is a verbal query.
    2. If the discussion relates to general documentation tips regarding a diagnosis or disease process, it’s likely educational in nature.
  2. Verbal queries need to follow the same compliance standards as written queries, so the CDI specialist needs to document that query and ensure there was no mention of a diagnosis, and the intent of the query (e.g., if the query was to clarify conflicting documentation in the record). CDI staff also needs to include the applicable:
    1. clinical indicators
    2. treatments
    3. diagnostic results
    4. progress notes
    5. nursing notes
    6. possible diagnosis options along with other or unable to determine
  3. Monitor and trend verbal queries for educational and quality purposes just as with written queries. “These can be used in outcome assessments so it’s very important that verbal queries are documented and reviewed,” Schade says.

The important focus is that all queries should follow the same policy/procedure/process and are not leading or offering the diagnosis, she says.

At a minimum, says Yuen, programs should track:

  • Name of the CDI specialist conducting the query
  • Name of the physician being queried
  • Subject of the query
  • Date, time, and location of the verbal query
  • Result (i.e., agree, disagree, other)

“Always encourage adherence to the practice brief guidelines regarding documentation of verbal queries,” says ACDIS Advisory Board member Wendy Clesi, RN, CCDS, CDIP, director of CDI services, Enjoin. “Verbal queries should be delivered in the same fashion as a written query (non-leading) including clinical indicators and treatments specific to the individual case (if using menu options, only offer clinically viable options specific to the scenario being presented), and the documentation of the occurrence for record keeping purposes should recount the conversation to ensure compliance with the query process. In regards to the specific scenario presented, it is always good practice to follow up a verbal query with a written or vice versa.”

If the verbal query is presented along with a completed written query, updating the response on the form itself should be sufficient for documentation purposes.

Tracking and query retention can be managed either manually and/or electronically. This will depend on the individual facilities resources.

Editor’s Note: ACDIS Advisory Board members offered the above responses as additional information following the November 2015 ACDIS Membership Quarterly Conference Call. Listen to a recording of the call or read additional questions and answers in the January/February edition of the CDI Journal.

A Note from the CCDS Coordinator: Do you know when your CCDS expires?

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

You worked too hard to earn the CCDS. Don’t let it slip away due to a clerical oversight.

By Penny Richards, ACDIS Member Services Specialist

Do you hold the CCDS certification? Do you know when it expires?

I recently heard from someone asking when his CCDS recertification is due. It expired and he wasn’t happy. He changed jobs but hadn’t communicated his new email address to us.

If we can’t reach you with an email reminder, how are you going to know when your CCDS expires?

To find out when your recertification is due, look on your CCDS certificate (it’s framed and hanging on the wall, right?) or look at the score sheet you received the day you passed the exam. Your CCDS recertification is due two years from the date you took the exam.

Recertifying is easy—most people list many more CEUS than the 30 that are required. Here is a link to a list of items you can submit for CCDS recertification.

There is a 45-day grace period to recertify without penalty and we will work with anyone with a recertification that is up to 12 months overdue. After a year, your CCDS is revoked and you must take the exam again in order to hold the CCDS.

Another reminder: ACDIS membership is not tied to CCDS certification. You don’t have to be an ACDIS member to hold the CCDS—and you don’t have to hold the CCDS to be an ACDIS member.

We encourage ACDIS membership for CCDS holders, if for no other reason than, with membership, you can earn 10 free continuing education credits each year toward the 30 you need to recertify. That’s just one great benefit of ACDIS membership.

Click here to email me if you need to know your CCDS recertification due date. Include your name, facility, home address, and phone number it is your responsibility to contact us. We’ll update the database as necessary and share the changes with customer service so they can update the main database, too.

You worked too hard to earn the CCDS. Don’t let it slip away due to a clerical oversight.

Weekend Reading: Communication with coders

CCDS Exam Study Guide

CCDS Exam Study Guide

Although a coder’s primary role is to translate physician documentation into codes for final billing and profiling purposes, they serve as an important member of the healthcare team. Coders serve as an important resource to the concurrent CDI specialist, providing knowledge regarding coding guidelines and regulations. At the same time, the clinical knowledge and expertise of those with nursing experience and serving in the CDI specialist role can provide the coding staff with a clinical perspective regarding conditions being monitored and treated by the physician. It is necessary for both professions to work cohesively to ensure accurate interpretation of clinical care in the final coding of the record.d

Daily conversation between CDI specialists and coders should occur regarding records when the final diagnosis-related group (DRG) of the coder does not match the DRG of the CDI specialist. A process to discuss these DRG discrepancies is important for accuracy in the final DRG and should occur before final billing of the case. With the over-arching goal of accurate code assignment and DRG grouping, the CDI specialist and coder should review the discrepancy and determine whether codes should be changed, a retrospective query should be placed, or the case requires escalation to the next level of review.

The reconciliation policy should include structure to the DRG discrepancy conversation and support a short discussion that identifies the coding issues. Conversation should be limited to the clinical document, the associated documentation, and the coding guidelines that address the situation. Discussion can occur verbally or through email communication, but if the discussion cannot quickly resolve the discrepancy, then the case should be escalated. Typically, the next level of review includes CDI and coding leadership in conjunction with the physician advisor or champion. When the case is escalated, information should be provided that demonstrates the issue, notes where documentation is included or missing, and recommendations from the CDI specialist and coder. This permits quick resolution and supports appropriate decision-making regarding the final coding and grouping of the record.

The role of the CDI specialist requires a unique knowledge base that combines clinical expertise and coding guidelines sanctioning the CDI specialist to serve as a resource to physicians and the healthcare team regarding documentation issues. Professionalism and the ability to investigate, translate, and consult with the healthcare team are necessary traits for success in the role. Ethical practice should be guided by principles set forth in professional papers identified by ACDIS and AHIMA as well as internal policies and procedures.

Editor’s Note: This excerpt is from the CCDS Exam Study Guide, Third Edition, written by Fran Jurcak, MSN, RN, CCDS, and reviewed by Laurie L. Prescott, RN, MSN, CCDS, CDIP.


Conference Update: Speaker Q&A

acdis_baseThe annual conference is less than 100 days away. Did you know that the full agenda is available for you to start mapping out your itinerary? Download the full conference brochure here.

As the countdown continues, we’ve spoken with Allison Clerval, RN, BSN, CCDS and Kathleen M. Shindle, RN, BSN, CCDS, who will present “To Err Is Human: CDI Impact on Patient Safety Indicators.”

Q: Why is it important for CDI programs to understand the impact on patient safety indicators?

Clerval : Patient safety indicators (PSIs) are a set of metrics, outlined by CMS, that provide info on adverse events and negative outcomes. They provide a standard for measuring care, and are becoming increasingly tied to reimbursement. Our industry has evolved from capturing CCs and MCCs for reimbursement to looking at the whole picture to reflect the true quality of care of our patients. CDI involvement in recognizing PSIs is just the natural progression of capturing diagnoses, present on admission status, the physician’s intention, and true quality concerns.

Q: How is your topic important for everyone regardless of professional background?

Shindle: We think it’s safe to say that the quality of care provided to our patients is a top concern for us all. We all play a role in capturing the true picture of our patient’s condition, whether it’s through documenting the care provided or accurately coding the record. Making sure we are only capturing true PSIs helps direct research to prevent future complications.

Q: As nurses, what unique perspectives do you bring to the CDI role?

Clerval: With nearly 50 years of clinical experience between us along with our years spent caring for surgical patients, we have experienced first-hand the quality concerns these PSIs were built to address. As surgical nurses, we have always worked as a part of a team. Our CDI role involves collaboration with coders, physicians, and performance improvement to identify PSIs and work as a team to discover solutions to provide the best quality of care for our patients.

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

Kathleen: As it relates to accurate reflection of the true patient condition, we feel that integrity is the most important quality. CDI professionals assess and review a patient’s medical record to ensure all the information documented reflects the patient’s severity of illness, clinical treatment, and the accuracy of documentation. We must sustain the highest level of ethical behavior, knowing what is right and what is wrong. We have to decipher when it is appropriate to query and when not to query and be honest in the face of identifying a PSI.

Q: Why do you think attending the ACDIS conference is important?

Clerval: We have a unique role that is often hard to fully articulate to those outside of the profession. While other conferences address issues pertinent to CDI, there is nothing like the ACDIS conference to address current topics in our field. The presentations encourage so much conversation back at our facility and help guide the development of new projects. From addressing mortality risk adjustment to capturing true PSIs, the knowledge you walk away with is incomparable. What better way to gain fresh insight than to learn from your peers?

Guest Post: Don’t let existing CDI processes hinder overall productivity

Kelli Estes

Kelli Estes, RN, CCDS

By Kelli Estes, RN, CCDS

Having worked with numerous CDI programs across the country, I can attest to the fact there are undoubtedly more variations of CDI process than you will ever care to know about. However, choosing the right process for your organization can make all the difference in the world.
How do CDI departments determine the right process?
First, start by assessing what works well for your CDI program then tease out the things you see as an opportunity for improvement.

  • Do you want to see increases in daily productivity but can’t seem to get there?
  • Do the CDI specialists review cases with similar acuity?
  • Are you just stuck and unable to increase the overall CDI review rate?
  • Are query rates consistent among CDI team members?
  • Do you constantly feel you need more staff to expand the reviews to all payers?
  • Are you letting coders be coders and the CDI staff be CDI specialists?

These are all great questions to consider when analyzing the overall effectiveness of your CDI program. Consider the following three processes which may hinder your CDI program’s productivity.

1.  CDI staff perform concurrent coding while doing CDI reviews

Most of the time, nurses who are hired as CDI specialists are not proficient coders. And, based on my experience, nurses do not feel comfortable shouldering the responsibility of coding while reviewing the case for documentation completeness. Providing coder education to nurses can help, but it isn’t an appropriate substitution for years of coding experience. Coding really needs to be left to the professionals.

You may then ask, “How will my CDI specialists ever generate an MS-DRG without coding the chart?” It is counterproductive for CDI specialists to code every single diagnostic condition and procedure when the professional coders will capture these things appropriately at discharge. CDI specialists need a “working knowledge” of coding while using the available tools necessary to generate a “working MS-DRG.”

However, if not careful, CDI specialists can easily spend 45-minutes or more generating an MS-DRG on cases that really have no query opportunity. Some programs don’t require the CDI specialists to assign MS-DRGs at all. If yours do, expect that mistakes will be made particularly if your program employs nurses or physicians and not coders.

Sure, sometimes coders make mistakes but CDI specialists should not become the coder’s watchdog either. Too often, I see animosity among coders and CDI specialists, generating an “us versus them” mentality.  The CDI specialists’ work should be complimentary to the work of the professional coder and serve as a resource to the coding team and vice versa.

2. Perform follow-up reviews on all cases through to discharge

It is not necessary to conduct CDI follow-up reviews on every single case through discharge.  CDI specialists should exercise their clinical skills in determining when it is appropriate to continue with follow-up reviews or close the case. Managing the caseload in this manner allows the CDI specialist to open more new cases for review and not continue a process that will hinder the overall productivity of the team.

3. Perform MS-DRG reconciliation on each case reviewed by the CDI specialists

Reconciling every case with an MS-DRG mismatch is likely not the best use of time. Yes, a reconciliation process is needed but consider employing CDI specialists’ involvement only to cases where queries were issued. After all, the benefit to reconciliation is to provide an estimate of the financial impact of the CDI program. The other 70% of charts that may or may not include mismatches do not require reconciliation unless you are holding the CDI specialists accountable for a level of accuracy consistent with professional coders. While it is possible to use the MS-DRG mismatches as opportunities for education with CDI staff, to include this as an ongoing step to the daily or weekly process will only prove counterproductive in the long run.

It is very important for CDI leadership to have a well-rounded understanding of what real CDI staff life looks like. There is room for many nuances and each facility comes with unique circumstances that require individualized processes to take shape.  Understanding what reports will be most meaningful to help your team capture results that provide a true picture of your program’s success.  As you can see with the three potential hindrances mentioned here, it is quite easy to institute steps through good intentions that end up eating away valuable time that could otherwise be channeled into more chart reviews resulting in more potential query opportunities. Choose a process that fuels your productivity for the future.

Editor’s Note: Estes has spent more than a decade as a clinical documentation specialist and consultant with DCBA, Inc., in Atlanta, Georgia. Since joining DCBA in 2005, Estes has assisted with project management in well over a dozen CDI program implementations across the country to include hospitals as small as 200 beds up to large teaching hospitals. This article was originally published in the DCBA eNewsletter CDI Talk.

Tip Tuesday: Careful mission statement development could poise programs for growth

How can a CDI program find success without a proper defination of what it means to fail?

Facilities need to develop a core mission statement to enable growth for their programs.

The CDI program of the future will collaborate closely with coders, as well as with a variety of other departments and within various healthcare settings, says past-ACDIS Advisory Board member Walter Houlihan, MBA, RHIA, CCS, FAHIMA, director of HIM and Clinical Documentation for Baystate Health in Springfield, Massachusetts.

Facilities need to develop a core mission statement to enable growth for their programs. Management needs to constantly and consistently evaluate new initiatives against that mission to avoid overburdening CDI staff and diluting the mission.

“It’s very important to develop a mission statement that tells what your program is all about,” Houlihan says.

New challenges in healthcare present opportunities for CDI efforts, and make it an exciting time to be involved with the clinical documentation improvement profession, he says.

Electronic health record implementation, integration, and optimization represents one such opportunity, says Houlihan, who helped the ACDIS Advisory Board draft its 2013 position paper, Electronic health records and the role of the CDI specialist.

“When CDI specialists see cloned data, there needs to be a decision regarding how to handle that situation,” he says. “In some cases, it might need to be a CDI query. In other situations, perhaps, that’s an educational opportunity for the physicians.”

Acting compliantly may seem like a simple directive. Generally speaking, no one wants to break the rules, and, yet, when those in power positions over CDI efforts direct staff to act in a questionable manner, CDI specialists need industry standards for support, Houlihan says.

In 2015, the ACDIS Advisory Board revised its Code of Ethics specifically incorporating examples of potentially difficult CDI-related experiences.

“As an association, [ACDIS] need[ed] to take a stance on this,” says Houlihan. “There’s a lot of pressure people are facing either from consultants or other avenues.”

Additional opportunities for CDI programs include involvement in denials management teams, and expanding into evaluation and management awareness in terms of helping physicians with their private practice documentation. Challenges with ICD-10, particularly with procedures, also represents an opportunity for CDI efforts. “Hospitals using CDI staff to look at surgeries was unheard of in the past,” Houlihan says, but “PCS is filled with new concepts that represent a new reality in ICD-10.”

Ultimately, facilities that align their mission with overall patient care will likely have the most successful CDI programs, and be well situated to handle new challenges, says Houlihan.

“Always keep the patient first,” he says. “It could be any one of us in the hospital, or someone we love. We believe if you focus on quality, the revenue will follow.”

Editor’s Note: Houlihan is the director of HIM for Baystate Health in Springfield, Massachusetts. He has worked in HIM for more than 30 years. He was elected to the ACDIS Advisory Board in 2013 and served through the end of 2015. Contact him at

Membership Update: Important ICD-10-PCS survey

Do you have what it takes to become a CDI specialist?

Take our survey!

Notice to our ACDIS members: ACDIS has recently learned that some minor procedures coded in ICD-10-PCS lead to surgical DRG assignments and unexpectedly high payments. This has led to some facilities opting not to code these procedures, believing that it may result in future recoupments from CMS.

Please take a moment to answer this anonymous six question survey. ACDIS plans to alert regulatory coding authorities with these findings in hopes to attain clarification.

Click here to take the survey. 

Thank you.

A Note from the Associate Director: Preparing for new products

Rebecca Hendren

Rebecca Hendren

By Rebecca Hendren

It’s been an exciting and illuminating month since I became the associate director for membership and product development for ACDIS. I took on the new role on January 4 and have been busy learning as much as I can about CDI, the association, and our members.

I’ve already had the pleasure of meeting some truly amazing people who are focused on lifelong learning and committed to helping others reach their potential—from ACDIS instructors, Laurie Prescott and Sharme Brodie, to CDI professionals who have created cutting-edge programs. I am looking forward to working with these individuals on books and other products as they share what they have learned. I am in awe of such people who are dedicated to doing their part to advance the whole profession.

While I may be new to ACDIS, I am not new to our parent company, HCPro, where I have spent the last 11 years working in the nursing, patient safety, quality, and accreditation markets. I plan to bring my experience in these areas to my work at ACDIS developing our line of books, webinars, and online learning materials.

If you are interested in being an author or have ideas for new products to share, please email me at I look forward to talking with many of you!