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Q&A: Missing documentation for acute kidney injury

ask ACDIS

Ask ACDIS all your CDI questions!

Q: We are currently coding a chart for an acute kidney injury which has the baseline serum creatinine and urine output missing from the chart. Is there something we can do to identify additional information before we have to query the physician?

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Tip: Show your ACDIS and CDI pride

With CDI Week 2017 only 74 days away, it’s time to get planning as to how you’ll show your CDI pride. In the past, CDI programs have taken whole team pictures together, thrown lunch parties, held after-hours get-togethers outside of the office walls, extended thanks to the most helpful physicians, and worn CDI-themed outfits to work.

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Guest Post: Minute for the medical staff, part 2

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

By James S. Kennedy, MD, CCS, CDIP

Definitions matter

Many clinical documentation improvement (CDI) programs now look to capture risk-adjusted conditions which help improve the capture of a patient’s severity of illness and risk of mortality regardless of setting. Since risk-adjusted outcomes depends on the definitions of coded diagnoses, let’s discuss current literature which supports specific clinical terms:

Shock: a life-threatening, generalized form of acute circulatory failure associated with inadequate oxygen use by the cells. In assessing the potential presence of shock, abnormalities of the skin (degree of cutaneous perfusion); kidneys (urine output); brain (mental status) are examined. While arterial hypotension (defined as systolic blood pressure of less than 90 mmHg, or mean arterial pressure of less than 65 mmHg, or a decrease of greater than or equal to 40 mmHg from baseline), is commonly present, it should not be required to define shock. As such, lactate levels in shock states are typically less than 2 mEq/L (or mmol/L) in shock states. In neonates, significant shock stigmata, such as decreased capillary refill, mottling, cool extremities, and tachycardia, can define shock in the right clinical circumstance.

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Note from the ACDIS Editor: Help identify CDI industry trends

LA-new headshot

ACDIS Editor Linnea Archibald

By Linnea Archibald

As you read last week, the theme for CDI Week 2017 will be “The Wild West: New Frontiers in CDI.” Though the theme offers numerous opportunities for fun CDI Week activities (cowboy hats and boots, anyone?), the theme also speaks volumes about the CDI industry as a whole.

As with any industry that’s been around for a while, things change. With more and more updates, regulations, and payment methodology changes, it seems the CDI field changes more rapidly than others. And ACDIS always seeks to keep its finger on the pulse of those changes.

To aid in this purpose, ACDIS undertakes a CDI industry survey each year to accompany the festivities of CDI Week. The survey analyzes trends in CDI, helping us report on the direction of the profession, new areas of expansion, and any other developments on the frontiers of this field.

This year’s survey consists of 38 questions spanning seven distinct sections, each probing a different area within the CDI profession. Click here to take the 2017 survey. [more]

Summer Reading: A letter to new CDI staff

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Laurie L. Prescott, RN, MSN, CCDS, CDIP

by Laurie L. Prescott, RN, MSN, CCDS, CDIP

Dear Clinical Documentation Improvement Specialist,

I remember my first day as a new CDI staff member very well. I had been through an extensive interview process—three interviews, a written test, and a meeting with the consulting firm that trained me. At the time, all I understood was that I was going review records and help medical staff meeting documentation needs. After more than 20 years of nursing experience, and time spent as a nursing school clinical instructor and in management, staff development, and healthcare compliance roles, I figured this would be an easy jump for me. It was a jump that felt like I had leapt right off a cliff.

I spent my first day training with two inpatient coders and the consultants. These two ladies were an interesting pair. One had been coding for more than 25 years, and I concluded she could diagnose most disease processes better than a number of physicians I knew. The second was new to the inpatient process, having coded in outpatient and clinic settings for a few years. We were implementing a new CDI program. Everyone looked to me to make this program a success. I soon understood this was much more of a challenge than I ever imagined.

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TBT: Primary, principal, and secondary diagnoses

ask ACDISQ: Sometimes I confuse the secondary diagnosis for the primary diagnosis. Do you have any tips for me to help me discern better?

A: This question touches on several concepts essentially at the core of CDI practices. I think you are confusing three definitions:

  1. Primary diagnosis
  2. Principal diagnosis
  3. Secondary diagnosis

Let’s take each of these individually.

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CDI Week 2017 theme chosen

CDI week poll results

The CDI Week 2017 theme poll results

Over the past week, ACDIS asked its members to choose a theme for CDI Week 2017. Every year, facilities across the country celebrate the efforts of their CDI programs for one week in September. This year’s event takes place September 18-22. To help facilitate the festivities, ACDIS chooses an annual theme.

The three options this year were:

  • Shoot for the stars
  • The wild west: New frontiers in CDI
  • Watering your CDI garden

After a week of racing neck-and-neck, the CDI Week 2017 theme has been chosen! This year’s theme will be—drumroll, please—“The Wild West: New Frontiers in CDI!”

While the ACDIS team will busily plan for CDI Week 2017 using the chosen theme, and we encourage you to do the same. Tell us your plans and let us know

how do you plan to use the theme and share your favorite CDI Week activity?

Email Linnea Archibald (larachibald@acdis.org).

Guest Post: Minute for the medical staff, part 1

James Kennedy, MD, CCS, CDIP

James S. Kennedy, MD, CCS, CDIP

By James S. Kennedy, MD, CCS, CDIP

Those of us who care for critically ill patients intuitively know who will have a long hospital stay and who will die. As such, intensive care unit (ICU) scoring systems based on clinical indicators such as Acute Physiology and Chronic Health Evaluation Three (APACHE-3) or Simplified Acute Physiology Score Three (SAPS III) in adults or Pediatric Index of Mortality Two (PIM2) in children have been developed, though validity in an individual patient varies.

Medicare, state governments, and private enterprise, such as Vizient, Truven, Quantros, and 3M, also have scoring systems based on the ICD-10-CM codes derived from explicit, clear, and consistent provider documentation. As such, how we define and document diagnoses that predict morbidity and mortality is essential if we want our patient’s risk to be accurately portrayed.

Physician definitions and documentation are crucial

In navigating the ICD-10-CM maze, we must remember the following as written in the Coding Clinic for ICD-10-CM, Fourth Quarter, 2016: [more]

Note from Associate Director: What to expect at the ACDIS Symposium: Outpatient CDI

R_Hendren

Associate Director Rebecca Hendren

By Rebecca Hendren

Outpatient CDI is a fast-growing area of focus for those working in the field. In a recent member poll, 33% of our audience reported that they either have an outpatient CDI program or they are planning to launch one within the next 12 months. The topic was a hot one at our 10th annual conference in May and many are looking for guidance regarding how to get started in outpatient CDI, including building a program, staffing, and determining return on investment.

Our new, two-day conference coming this September will answer many of these questions and help us kick-off our CDI Week celebrations. The ACDIS Symposium: Outpatient CDI, being held September 18-19 in Oak Brook, Illinois, features presentations from organizations who have already built successful outpatient CDI programs and who will share their experiences in getting started and maintaining a program.

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Summer Reading: Tips for preparing for the CCDS exam

Jurcak

Fran Jurcak, MSN, RN, CCDS

By Fran Jurcak, MSN, RN, CCDS

Once you have met the two-year minimum work experience requirement required to sit for the Certified Clinical Documentation Specialist (CCDS) credential exam, it’s time to study. Start by reviewing CCDS Exam Candidates Handbook for information on applying to sit for the exam as well as the process for taking the test. The following are a few additional tips that many successful candidates have used to earn their certification:

  • Discuss with peers and supervisors
  • Join a study group
  • Visit the CCDS discussion board on the ACDIS Forum
  • Start studying early like a few months prior to sitting for the exam
  • Review a new content area each week
  • Spend extra time studying areas where you feel less confident
  • When reviewing practice questions multiple times, make sure you understand the concept and don’t just memorize an answer
  • Take a day or two to prepare your mind and body for the exam
  • Get a good night’s sleep and eat a good meal before taking the exam
  • Leave plenty of time to arrive for the exam

Once you are set to begin the exam, take a deep breath, exhale, and let your knowledge and experience guide you through successful completion of the certification.

Editor’s note: This article is an excerpt from the “CCDS Exam Study Guide,” by Fran Jurcak, MSN, RN, CCDS. To read more about certification, visit the ACDIS website, here.