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TBT: ACDIS/AHIMA ‘Guidelines for Achieving a Compliant Query Process’ outlines new query opportunities

CDI JournalEditor’s Note: In social media memes Throw-back Thursday (TBT) generally means someone has shared an old high school photo of you, something you most likely wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We thought we’d pick up on the theme and occasionally go back into the archives to highlight some salient CDI tid-bit rather than our fashion sense (or lack there-of).  Today, we’ve chosen to pluck information from the April 2013 edition of CDI Journal in which the ACDIS/AHIMA joint committee published the latest compliant query guidance Guidelines for Achieving a Compliant Query Process.” Specifically, the new practice brief offers new insight into how to compose multiple choice and “yes/no” queries in an effective and compliant manner. It also provides some additional definitions around the idea of what constitutes a “leading” query.

Guidelines for Achieving a Compliant Query Process

Although open-ended queries are preferred, multiple choice and “yes/no” queries are also acceptable under certain circumstances.

To support why a query was initiated, all queries must be accompanied by the relevant clinical indicator(s) that show why a more complete or accurate diagnosis or procedure is requested. Clinical indicators should be derived from the specific medical record under review and the unique episode of care. Clinical indicators supporting the query may include elements from the entire medical record, such as diagnostic findings and provider impressions. A query should include the clinical  indicators, and should not indicate the impact on reimbursement.

A leading query is one that is not supported by the clinical elements in  the health record and/or directs a provider to a specific diagnosis or procedure. The justification (i.e., inclusion of relevant clinical indicators) for the query is more important than the query format.

Multiple-choice query formats should include clinically significant and reasonable options as supported by clinical indicators in the health record, recognizing that there may be only one reasonable option. As such, providing a new diagnosis as an option in a multiple choice list—as supported and substantiated by referenced clinical indicators from the health record—is not introducing new information. Multiple-choice query formats should also include additional options such as “clinically undetermined” and “other” that would allow the provider to add free text. Additional  options such as “not clinically significant” and “integral to” may be included on the query form if appropriate.

The “yes/no” query format should be  constructed to include the additional options associated with multiple choice queries (i.e., “other,” “clinically undetermined,” and “not clinically significant and integral to”). Yes/no queries may not be used in circumstances where only clinical indicators of a condition are present and the condition/diagnosis has yet to be documented in the health record. Also, new diagnoses cannot be derived from a yes/no query. In such circumstances, open-ended or multiple-choice query formats must be used. It is not considered leading to include a new diagnosis as part of a multiple-choice format when supported by clinical indicators.

Editor’s Note: Have a tough query situation your facility is dealing with? Join Cheryl Ericson, MS, RN, CCDS, CDIP, and Mark LeBlanc, RN, MBA, CCDS,  on Tuesday, June 10, to review best practices and sample queries to help you ensure your program is both compliant and effective in the 90-minute audio conference “Physician Queries: Ensure Effective, Compliant, Regulatory-based Clarifications.”

Happy Health Information Professionals Week and Certified Nurses Day!

Celebrate spring and professional achievement too!

Celebrate spring and professional achievement too!

Maybe it’s the promise of spring that has everyone in the mood to celebrate, after all tomorrow is the first day of that blissful season. Regardless, ACDIS stands at the ready to raise a toast to the two sets of professionals who support CDI efforts all year long.

First, this year’s Health Information Professionals Week takes place March 16th-22nd. This week provides an opportunity to showcase the thousands of HIM professionals who perform their duties throughout the year. ACDIS joins with AHIMA in its 25th anniversary celebration “Transforming Healthcare with Information.”

“The work HIM professionals do to ensure the integrity of health information is imperative to clinical and administrative decision making. Access to accurate information helps all of us make important decisions and leads to a healthy society,” said AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA, in a press release.

AHIMA kicked off its celebrations earlier this with “Hill Day” where HIM professionals visit Washington D.C. for lectures and set aside time to meet with their Congressional representatives to talk about the importance of the role of HIM in today’s healthcare landscape.

Secondly, Certified Nurses Day takes place today Wednesday, March 19, as a national day to honor and recognize the important achievement of nursing specialty and subspecialty certification. Obtaining certification represents a milestone of personal excellence along one’s professional journey and we at ACDIS are proud to join our fellow professional organizations the American Nurses Credentialing Center (ANCC) and the American Association of Critical-Care Nurses (AACN), among others, in congratulating those nurses who go the extra mile to earn certification in their areas of specialty.
How many professionals from your state hold the CCDS certification?

1,800 hold the CCDS certification–are you ready to get yours?

Those who have chosen to sit for the Certified Clinical Documentation Specialist exam to obtain their CCDS credential understand the value of certification. Proudly displaying your CCDS pin and certificate not only demonstrates pride in your achievements but also illustrates to the world a personal dedication to industry standards and professionalism.

According to data collected by the American Board of Nursing Specialties in 2013, nurses in the U.S. and Canada held more than 683,684 certifications, an increase of more than 87,111 certifications compared to 2012 survey data. These certifications were granted by 27 different certifying organizations, and 122 different credentials designate these certifications.
For ACDIS’ part, the first CCDS exam was held in May 2009 and 39 months later, in August 2012, the 1,000th person passed. Just a few months later on November 22, the 1,500th person earned the CCDS.
Today, there are nearly 1,800 CCDS credentialed CDI professionals in the country more than 400 others registered to sit for the exam. A majority of CCDS holders are RNs, but ACDIS is proud to count many HIM professionals, as well as quality improvement personnel and physicians, among those who have earned the CCDS.
Whether you have your CCDS or another credential, ACDIS salutes you for professionalism and honor you for taking those next steps to demonstrate your commitment to the healthcare profession.
As a reminder, our parent company HCPro offers a number of ANCC-approved webinar programs including several which are also approved for CCDS, AAPC, and AHIMA credits. To learn more, visit
Upcoming programs include:






ICD-10 Coding Proficiency for Home Health: Coding Neurological Diagnoses, Circulatory Diagnoses, and Wounds – Part 3



ICD-10 Coding Proficiency for Home Health: Implementing an Action Plan – Part 4



Alternative Sanctions and CoP Compliance (WT)



Principal Diagnosis Selection: Essential guidelines for ICD-10 implementation  (WT)



Query Compliance: Tools to Identify Query Successes and Opportunities (WT)



Face-to-Face Physician Encounters: Strategies for Compliance (WT)



Quality Improvement Strategies (WT)



Management of Chronic Conditions in Homecare (WT)

CDI efforts take center stage at AHIMA conference



The 2013 AHIMA conference is in full swing today, but it’s educational sessions have been focused on clinical documentation improvement efforts since the conference opened on Saturday with sessions by Andrew Rothschild, MD, MS, MPH, CCDS, FTI Consulting, Dianne Haas, PhD, RN, TrustHCS, Brigid Caffrey, CCS, OptumInsight, and ACDIS book author Marion G. Kruse, RN, MBA. 

This morning there was a CDI networking breakfast and this afternoon sessions include:

ACDIS Director Brian Murphy arrived at the Atlanta, Georgia conference center last night and will be attending sessions, shaking hands at the ACDIS booth #1143, and hobnobbing at after-hours events tonight. So be sure to try and spot him! If you see him, be sure to take your photo with him and either tweet it @ACDISDirector or @ACDIS. If you’re not on Twitter, email it to Melissa Varnavas to post! Throughout the conference we’ll be giving away a free Boot Camp seat, a year’s membership to ACDIS, and other great items.

Tomorrow sessions include:

Although I wish I could be there, I know conference attendees will be learning a lot from our AHIMA colleagues and are in good hands with the tremendous HCPro staff in attendance. I can’t wait to hear all about it!

Guest Post: AHIMA director offers CDI insights

AHIMA releases CDI toolkit.

Endicott says increasing healthcare complexity requires CDI input.

By Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA

Clinical documentation is the foundation of all aspects of healthcare, including data analysis, research, communication between caregivers, reimbursement, and most importantly, quality patient care.
The concept of clinical documentation improvement (CDI) is not new; however, the increasing complexity of the healthcare reimbursement system, quality initiatives, and the transition to ICD-10-CM/PCS put CDI programs in the spotlight. This article provides a high-level view of CDI programs, qualifications for CDI professionals, and future opportunities for this growing profession.
CDI programs
The purpose of a CDI program is to initiate concurrent and/or retrospective reviews of inpatient records to identify conflicting, incomplete, or nonspecific provider documentation. These reviews usually occur on the patient care units or remotely via the electronic health record (EHR).
The goal of these reviews is to identify clinical indicators that support the assignment of ICD-9-CM diagnosis and procedure codes. CDI professionals often use written queries in the health record to accomplish this goal. They may also use verbal and electronic communications. These efforts result in improved documentation, coding, reimbursement, and severity of illness/risk of mortality classifications.
Although CDI programs traditionally occur in the acute inpatient setting, they are being implemented in other healthcare settings as well, including acute rehabilitation hospitals and skilled nursing facilities.
CDI professionals
Individuals working in a CDI role need very strong clinical and analytical skills as well as expertise in coding. Most commonly, CDI professionals have several years of experience in inpatient coding or a nursing background. The essential coding skills that these individuals must possess include the following:
  • In-depth knowledge of ICD-9-CM guidelines and conventions
  • Access to and awareness of pertinent AHA Coding Clinic references
  • Understanding of the MS-DRG reimbursement system, including relevant MCCs and CCs that affect the MS-DRG assignment
CDI professionals must communicate effectively, both verbally and in writing, with clinical staff. CDI professionals routinely communicate with providers about documentation improvement and education, so it’s important that they are well-spoken and professional at all times to build trust and rapport with the clinical staff.
CDI professionals typically hold one or more of the following credentials:
  • Clinical Documentation Improvement Practitioner (CDIP)
  • Clinical Documentation Specialist (CCDS)
  • Registered Health Information Administrator (RHIA)
  • Registered Health Information Technician (RHIT)
  • Certified Coding Specialist (CCS)
Looking ahead to ICD-10-CM/PCS
The United States will transition from ICD-9-CM to ICD-10-CM/PCS on October 1, 2014. This transition is far more complicated than the annual code update to which coders and CDI professionals are accustomed. ICD-10-CM/PCS codes bring with them increased specificity, laterality, updated terminology, and new and revised guidelines. Hospitals should perform a gap analysis of physician documentation to identify opportunities for education and documentation improvement.
CDI professionals are the ideal individuals to educate physicians about the documentation requirements for these new code sets because they’ve already built trust and rapport with the clinical staff. CDI staff should be fully trained in both ICD-10-CM and ICD-10-PCS. This includes receiving in-depth training on the ICD-10-CM/PCS guidelines.
Future roles
Quality documentation is necessary in all healthcare settings. Outpatient settings, such as clinics, physician offices, and ambulatory surgery centers can reduce denials and improve data quality by employing CDI professionals to review records and identify deficiencies.
Other non-acute care settings can also benefit from a CDI program. These include long-term care, skilled nursing, home health, and rehabilitation centers. The future is bright for CDI professionals.
Editor’s Note: Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, is a director of HIM practice excellence at the American Health Information Management Association in Chicago. E-mail questions to Endicott at
This article was originally published on

April CDI Journal released

The April edition of the CDI Journal is now available. It includes an analysis of the new physician query practice brief as well as the brief in its entirety. It also includes the following articles:

Download the PDF of the entire April issue of the CDI Journal
ACDIS/AHIMA brief provides additional query guidance
Director’s note: ACDIS/AHIMA query brief: Take a bow, members!
Guidelines for Achieving a Compliant Query Practice
Pediatric hypertension: The cause or the effect?
Meet a member: Thirty-two-year career ends with CDI efforts
Do not let documentation disconnect fester
Avoid the DRG ‘grab bag’ mentality: Help the physician instead
Accurate documentation for dying patients
Ask ACDIS: Advisory Board offers members insight



All this week ACDIS Director Brian Murphy has been milling around the McCormick Place Convention Center rubbing elbows with HIM professionals and industry experts at the 84th annual American Health Information Management Association (AHIMA).

We’re not jealous. Okay, maybe I am just a little bit. After all, it has been two years we held our own conference in the ‘Windy City,’ two years since we were able to enjoy Chicago pizza and that terrific Garrett Popcorn Chicago blend.  More importantly, however, I am jealous of the hundreds of connections coders, HIM, and CDI professionals have the opportunity to make during this extraordinary week.

AHIMA planned many networking events and the educational sessions seem to provide additional focus on CDI efforts. AHIMA is also offering CCDS credits for many sessions which relate to CDI. Some of the sessions which caught my eye included:

  • When Queries Alone Just Don’t Cut It: Complementing the Query Process
  • Taking the Guesswork out of CDI
  • Integrating CDI and CAC Initiatives

And then there was the “Querying for ICD-10″ presented by our own CDI Boot Camp instructor and ACDIS Advisory Board member Cheryl Ericson.

I’m sure the ACDIS team in attendance will bring back all sorts of educational goodies. If you happen to be at the conference stop by Booth # 1227 and say hello!

Stop by booth #1227


ACDIS/AHIMA joint project seeks volunteers

ACDIS invites you to join a work group to research industry needs and develop best practices for physician/provider queries. The work group deliverables will serve to educate members and the industry on ongoing physician and provider query questions, and will be conducted in conjunction with the American Health Information Management Association (AHIMA).

Work group activity will be conducted via weekly one-hour conference calls. No face-to-face meetings are planned. The weekly calls will begin in July. To volunteer, send a resume, a brief email statement of your qualifications, and a short description of your experience with physician queries to ACDIS Director Brian Murphy at

Please note that the deadline for response is the close of business on June 15th.

Maybe, possibly, definitely: Stay informed regarding ICD-10 delay

Which countdown to ICD-10 calendar will you use?

On February 14, CMS acting administrator Marilyn Tavenner told American Medical Association (AMA) meeting attendees that CMS would “reexamine” the timeline for ICD-10-CM/PCS implementation. Tavenner offered no details, just the vague possibility of potential reconsideration.

The healthcare industry jumped with the news.

American Health Information Management Association (AHIMA) immediately published a release urging healthcare professionals to move forward with their ICD-10 implementation and training plans, and downplayed the announcement, pointing its vague language.

“This is a promise from CMS to examine the timeline, not to change it,” said Dan Rode, MBA, CHPS, FHFMA, vice president for advocacy and policy at AHIMA, in the release. “But government officials are sending mixed signals that many in the healthcare community will interpret as a reason for delay.”

The AMA celebrated.

“The timing of the ICD-10 transition could not be worse for physicians as they are spending significant financial and administrative resources implementing electronic health records in their practices and trying to comply with multiple quality and health information technology programs that include penalties for noncompliance,” wrote Peter W. Carmel, MD, AMA president in a February 16 release. “Burdens on physician practices need to be reduced—not created—as the nation’s health care system undertakes significant payment and delivery reforms.”

The very next day, February 15, HHS Secretary Kathleen Sebelius said “the federal government will delay for an unspecified time the implementation date for the ICD-10 diagnostic and procedural coding system,” HealthLeaders Media reported.

Specifically, the HHS release stated that the agency “will initiate a process” to delay the ICD-10 implementation date for “certain health care entities.”

And that was pretty much it.

The rest of the release reiterates that the provider community feels burdened by the ICD-10 implementation, but also reiterates the importance of the move to ICD-10 because it will “provide more robust and specific data that will help improve patient care.”

Meanwhile, CMS confirmed to ACDIS’ parent company HCPro Inc., that the agency will use the rulemaking process when revisiting the ICD-10 implementation timeline; a process known to be lengthy, a process that does not always furnishes an expected result (meaning after the rulemaking CMS may just decide to keep the implementation date firm).

So multiple experts from ACDIS Advisory Board members to AHIMA directors repeated the refrain,; “Stay the course with ICD-10 implementation.”

I’m on their side.

In a phone conversation earlier this week, an ACDIS member told me that she was glad to hear CMS delayed ICD-10 by two years. Two years, she said.

Of course, I asked where she got her information and she cited some reputable sources which, on closer examination, actually said nothing of the sort.

All this commotion—all this maybe, possibly, definitely thinking about it—may ultimately cause serious difficulties for those in the midst of ICD-10 implementation plans. The possible delay could cause facility administrators to pull back the purse strings on training funds. Programs could decide to delay important technology purchases to save money since the implementation date isn’t imminent.

Meanwhile, we hear how far behind facilities actually are in their ICD-10 planning. CDI staff (according to a recent survey) say they do not even know if a ICD-10 implementation committee is meeting at their facility or what will be expected of them as the coming change draws near. Possibly postponing the actual “go-live” date only adds to facility procrastination on these issues.

The more advanced facilities have already evaluated their staffing needs in terms of CDI specialists’ concurrent record reviews and coding needs. These facilities have already budgeted for additional employees and charted a course for staff member training beginning with anatomy and physiology. Even more advance programs have already begun reviewing their top MS-DRGs for documentation improvement opportunities related to ICD-10.

History may prove me wrong (especially as rumors also abound about HHS opting to skip ICD-10 and jump directly to ICD-11!) but I remain convinced that ICD-10 implementation is inevitable and that the sooner facilities prepare themselves the better.

AHIMA names new chief executive, annual conference starts Sunday

Meet Brian Murphy at AHIMA Booth 1207

Lynne Thomas Gordon, MBA, RHIA, FACHE, took over as CEO of AHIMA on September 29, according to a recent AHIMA release. Thomas Gordon joins AHIMA after serving as associate vice president for hospital operations and director of the Children’s Hospital at Rush University Medical Center. She also is a member of the Rush University faculty in the graduate program in health systems management.

“The combination of Lynne’s executive skills and healthcare knowledge will help lead AHIMA and its members through complex issues and the healthcare industry’s transformation of managing and integrating HIM with a new generation of technology,” said AHIMA Board President Bonnie Cassidy in a release.

The 83rd AHIMA Convention and Exhibit begins Sunday and ACDIS is proud to support the efforts of the HIM professionals who work so diligently to ensure the accuracy and security of the medical record. A few former ACDIS Advisory Board members will be presenting during the conference. ACDIS Director Brian Murphy will be in attendance, so be sure to stop by booth 1207 and pay him a visit.

Also, the HCPro flagship publication Medical Records Briefings is celebrating its 25th anniversary this year and will cap-off the festivities during the upcoming AHIMA conference. Word on the street is that cupcakes will be available at booth 1207 during the afternoon break on Monday, so be sure to swing by and pick one up!

Book Excerpt: Look to others for advice when starting a new CDI program

The Clinical Documentation Improvement Handbook, Second Edition

A savvy CDI steering committee looking to implement a new CDI program should seek the opinion of other facilities in their vicinity, perhaps even visiting other programs and shadowing CDI professionals on their rounds. Such engagement provides anecdotal first-hand experiences to help shape the roles and responsibilities of the CDI staff and it helps the steering committee gauge potential problems.

The group may also decide to enlist the assistance of professional associations; both the American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS) help foster local meetings in various states where members freely discuss program troubles and triumphs. Furthermore, ACDIS surveys its members annually regarding the structure, staffing, and focus of CDI programs.

For example, two studies, an April 2010 CDI Staffing Survey featuring responses from 85 CDI department directors and a July 2010 CDI Program Benchmarking Survey featuring 482 responses from a variety of CDI professionals, both indicated that a majority of CDI programs employ registered nurses as CDI specialists who report to the HIM director.

Whether a facility uses coders, nurses, or some combination of both, and regardless of to whom the CDI staff reports, the goal of capturing complete and accurate documentation should not be compromised in favor of other agendas. Without clearly defined responsibilities, a case manager who also performs some CDI work may push one set of responsibilities aside for another given the limitations of time, experience, and administrative expectation. Conversely, a coder might not pursue a query if tasked with concurrently coding a chart, meeting productivity standards, and maintaining discharged, not final billed (DNFB) goals.

Editor’s Note: This article is an excerpt from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition written by Marion Kruse, MBA, RN and Heather Taillon, RHIA, CCDS.