By Rebecca Hendren
One of the tasks I enjoy most in my role as the ACDIS associate director of membership and product development is getting to interact with our book authors and CDI Boot Camp instructors. Many of these talented professionals have been involved in CDI longer than they’d care to admit, but through that experience have developed a keen insight into advancements in the industry along with a desire to share that knowledge with ACDIS and with the larger clinical documentation improvement community.
Once a year, at the ACDIS national conference, we also get to see their expertise in action as they share pearls of wisdom in one of three pre-conference events.
This year, CDI Education Director Laurie Prescott, MSN, RN, CCDS, CDIP, CRC, and Shannon McCall, RHIA, CPC, CCS, CCS-P, CPC-I, CCDS, CEMC, CRC, director of the HCPro suite of coding Boot Camps, bring a two-day version of their risk-adjustment record review and coding program.
If you never been in a class with these two, trust me, it’s a blast. I know. I know. As the associate director of membership and product development, I’m supposed to tell you that—but I mean it. As someone who comes from neither a clinical or coding background, diving into something as complex as coding guidelines’ application to CMS-Hierarchical Condition Category (HCC) methodology is more than intimidating but these lovely ladies do a tremendous job of providing detailed instruction on the individual HCCs and opportunities for improved documentation with clinical scenarios to demonstrate how these concepts can be incorporated into CDI practice.
As an ACDIS staff member, I’m particularly lucky because I get to bounce around to a number of different sessions. So, I’m also looking forward to catching up with two of my favorite CDI people Richard Pinson, MD, CCS, and Cynthia Tang, RHIA, CCS, co-creators of the beloved CDI Pocket Guide. They’re teaching a pre-conference event designed to help CDI programs break down departmental silos into a collaborative, cohesive team. It’s called “Building a Best Practice CDI Team,” and throughout the program Pinson and Tang will explore the importance of understanding how your medical staff thinks and learns—and adjusting CDI efforts accordingly.
“A successful CDI team is based on engagement of medical staff obtained through effective communication,” says Pinson. “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.”
Over the course of the past year, I’ve also had the distinct pleasure of being able to work with Trey La Charité, MD, FACP, SFHM, CCDS, medical director of clinical documentation integrity and coding for UT Hospitalists at the University of Tennessee Medical Center (UTMC), as he crafted not one but two books—The CDI Companion for Physician Advisors and The CDI Field Guide to Denial Prevention and Audit Defense. That’s in addition to the volume, The Physician Advisor’s Guide to Clinical Documentation Improvement, that he co-wrote with James S. Kennedy, MD, CCS, CCDS, CDIP, president of CDIMD-Physician Champions.
I know how beloved both doctors La Charité and Kennedy are within our community and know how much people love their pre-conference deep-dive into essentially everything a CDI physician advisor needs to know to help CDI programs flourish. The second day of this preconference event includes a second track case study featuring Erica E. Remer, MD, FACEP, CCDS, and Kelly Skorepa, BSN, RN, CCDS, corporate manager of clinical documentation integrity for University Hospitals Health System in Cleveland. I’ve heard Remer speak during ACDIS Radio programs, so I’m interested in learning more from her as well.
If you’re already signed up for one of these pre-conference events, I’m sure you’re as excited as we are. If you’re still on the fence about whether these extra courses will meet your CDI program’s educational needs, check out the agendas on the ACDIS website or feel free to reach out to me to learn more.
Editor’s note: Rebecca Hendren is the associate director of membership and product development at ACDIS. If you have any questions, please reach her at email@example.com.
By Laurie L. Prescott, RN, MSN, CCDS, CDIP
It has been 10 years since I turned the focus of my career to the practice of CDI. About a year ago, I found myself calling it a “profession.” I have been a proud member of the nursing profession for more than 30 years. In both my personal and professional life, I tried my best to represent my profession and demonstrate that nurses are highly competent, knowledgeable leaders in providing healthcare to patients. Nurses have been granted the privilege of witnessing and assisting others in their most intimate moments of life.
I never wanted to minimize the role of a nurse, nor misrepresent it in any way. I feel very much the same about the profession of CDI. We serve a very important role in our organizations in that we work to ensure our patient’s stories are told accurately and completely.
The profession of CDI encompasses a number of different titles, credentials and professions besides nursing, to include medicine and coding. And I am sure no matter how a person landed in CDI they too are as proud of their specific profession that started them off as I am of my nursing background. And I am sure, too, that most are also proud of the fact they are now a member of the CDI profession. (Read the recently released “CDI: More than a credential,” position paper from the ACDIS Advisory Board.)
Google the word profession and the definitions returned are all similar. Most state that a profession describes an occupation requiring specialized education, knowledge, training, and ethics. Members of a profession are expected to meet and maintain a common set of standards. Skills and knowledge are obtained through the process of lifelong learning and continuing professional development. Indeed, the ACDIS Code of Ethics reinforces that commitment to lifelong learning.
I was always taught that a profession must have a developed body of knowledge. The ACDIS Code of Ethics addresses this as well with the statement, “Clinical Documentation Improvement Professionals must advance their specialty knowledge and practice through continuing education, research, publications, and presentations.” It is up to each and every one of us to grow our body of knowledge.
So my question to you is—what have you done lately to represent your profession?
We all need to be leaders. That does not mean you have to speak at the national conference, or write articles and books, but it could mean becoming a leader within your own hospital organization or helping with your local ACDIS chapter.
When I was working daily in the CDI role, I spread the word of CDI in an activity I called the “CDI Road Show.” I took the road show to anyone, any department that invited me. (And even to some that did not extend an invitation!) I wanted everyone to know what we did because their support of those efforts could help foster our success.
I wanted to represent my profession well; meaning I tried to demonstrate competence, knowledge, and commitment to ethical practice in every activity and exchange performed. This commitment was as much for myself as it was for all the CDI specialists I worked with. If I presented as well prepared and knowledgeable to a provider, the next time that provider spoke to another team member he or she would understand the skills our CDI team brings to the game. If I could speak concisely to administration and communicate both the value of CDI and the needed resources, the administrative team would see all CDI staff as professionals, too.
And so, I encourage you to step up. Volunteer to serve on a committee. Start a “road show” of your own. Mentor a new CDI. Learn something new today.
Most importantly, walk strong and tall and demonstrate to the world the CDI professional that you are.
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, is a CDI Education Specialist at HCPro in Danvers, Massachusetts. Contact her at firstname.lastname@example.org. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.
Q: I’m having problems determining the correct coding guidelines for chronic obstructive pulmonary disease (COPD) and pneumonia. Have the guidelines changed regarding COPD and pneumonia? Do you now have to code the pneumonia as a COPD with a lower respiratory infection?
A: Yes, the AHA’s Coding Clinic for ICD 10-CM/PCS, Third Quarter 2016, discusses an instruction note found at code J44.0, chronic obstructive pulmonary disease with acute lower respiratory infection requires that the COPD be coded first, followed by a code for the lower respiratory infection. This means that the lower respiratory infection cannot be used as the principal diagnosis. We would assign code J44.0 (chronic obstructive pulmonary disease with acute lower respiratory infection) as the principal diagnosis, followed by an additional code to identify the lower respiratory infection.
If the patient has an acute exacerbation of COPD and pneumonia, we would assign both codes J44.0 (chronic obstructive pulmonary disease with acute lower respiratory infection) and code J44.1 (chronic obstructive pulmonary disease with acute exacerbation). Per the instructions, either code may be sequenced first and it should be based on the circumstances of the admission, followed by a code to identify the infection, such as code J18.9 (pneumonia, unspecified organism).
CDI specialists and/or the coding staff need to clarify the type of infection to ensure the proper code assignment. There does seem to be some concerns regarding classifications of lower respiratory infection. Per the Coding Clinic, acute bronchitis and pneumonia are both included in code J44.0 (lower respiratory infections). Influenza, on the other hand, is not included in code J44.0 because it is considered both an upper and lower respiratory infection.
Additionally, the type of pneumonia needs to be clarified. For example, aspiration pneumonia (code J69) is not classified as a lower respiratory infection, but as a lung disease due to the external agents. To assign the appropriate code in the case of aspiration pneumonia, we would need to know the external agent, i.e. milk versus vomit.
Editor’s Note: Sharme Brodie, RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at email@example.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.
by Laurie L. Prescott, MSN, RN, CCDS, CDIP
CDI specialists depend on clinical indicators to support queries. Hospitals and physicians need clinical indicators to support the validity of documented diagnoses.
Clinical indicators include patient presentation, symptoms and complaints, lab and diagnostic studies, and ordered treatments such as medications, interventions, monitoring, and assessments. You can find clinical indicators in the documentation of nursing and ancillary staff. As part of our work with clinical validation, all CDI specialists and coders have to work with providers to ensure diagnoses are well supported within the record. It is not enough to obtain documentation of a diagnosis; we must ensure the record clearly supports its presence.
To concentrate on these issues, we have developed a new boot camp to help increase understanding of pathophysiological concepts. The Mastering Clinical Concepts in CDI Boot Camp is designed to assist in the process of clinical validity reviews by examining a number of diagnoses common to both CDI and audit challenges. The Boot Camp discusses diagnostic interpretations, signs and symptoms, and common treatments and covers interventions to strengthen students’ knowledge and competence in record review.
These concepts will assist CDI teams in identifying vague or missing diagnoses regarding neuro, respiratory, cardiac, gastric, liver, musculoskeletal, endocrine, and renal diseases among others and increase staff confidence in speaking to providers and working to ensure adequate documentation in the record. During class, we use real-life scenarios to drive discussions about challenging CDI reviews and help our students:
- Increase your understanding of key pathophysiological concepts
- Improve the quality of clinical indicators used when you query
- Cultivate critical thinking skills for use with data involving complex clinical concepts
- Improve your ability to distinguish evidence-based clinical indicators from other data in the record
I’m looking forward to teaching this new boot camp aimed at experienced CDI professionals looking to advance their careers with next step training. This course is also valuable for coding staff who wish to increase their clinical understanding of the records they review.
We look forward to seeing you in class!
Editor’s note: Prescott is the CDI education director for ACDIS/HCPro. She is a frequent speaker and author of The Clinical Documentation Improvement Specialist’s Complete Training Guide.
by Laurie L. Prescott, MSN, RN, CCDS, CDIP
I spend much of my time communicating with CDI managers and directors. They work tirelessly to develop and nurture CDI departments, focusing much of their time on training new CDI staff and evaluating the experienced CDI professionals in their care in order to identify areas of education need. Often CDI directors fight for funding to buy the newest software with the latest and greatest bells and whistles. I remember how excited I was to use the new encoder when I was a young CDI specialist. Now there’s computer assisted coding software, software that prioritizes and develops work lists, tracking software, query opportunity software, etc., etc.
This all sounds great, but I think such technology may also be a hindrance when training new staff.
Experienced CDI specialists often complain about the lack of critical thinking skills within the ranks of those new to the industry. I often hear that it is difficult to teach a new CDI staff person because “no one uses the books anymore.” I hear that new CDI staff simply follow the query leads fed to them from the software programs and that they are not thinking for themselves. Managers also complain that many of the more experienced staff seem to be “coasting in their retirement job,” don’t wish to engage with the medical staff or challenge the status quo, and have become overly dependent on the EHR and the software to direct their day-to-day activities.
Please don’t get me wrong, I love the technology we have at our fingertips, but we also must understand that we, the CDI specialists, should be directing the software and not the other way around. This technology is meant to be a tool that assists the living, breathing, thinking CDI specialists. We need to use the skills our experience and intellect bring to the table whether those abilities be regulatory or coding knowledge, clinical expertise, communication skills, or, more importantly, a collection of these talents.
We speak about software in our CDI Boot Camps all the time. In these discussions, I encourage new CDI staff to pick up a code book, and a DRG Expert, and work the chart the old-fashioned way. Many groan when I mention such prehistoric methods to practice CDI, but there is a method to my madness. To effectively work as a CDI and to use the technology to its utmost value, we need to understand the inner workings and decisions the software program was designed to make. We need to know when the software misses something or inappropriately identifies a diagnosis that does not exist.
Critical thinking is defined as an active process of applying, analyzing, synthesizing, and evaluating information. The Critical Thinking Community (http://www.criticalthinking.org/pages/defining-critical-thinking/766) describes it as “ entailing the examination of those structures or elements of thought implicit in all reasoning; purpose, problem, or question-at-issue; assumptions; concepts’ empirical grounding; reasoning leading to conclusions; implications and consequences; objections from alternative viewpoints; and frame of reference.”
My simplified definition is that critical thinking is “thinking about your thinking,” questioning all conclusions and working to ensure you interpret all the facts and evidence correctly.
Critical thinking has been a buzz word for years, especially in healthcare. Many go through the motions of the day, not taking the extra energy to actually think through the record and identify those opportunities requiring intervention. CDI professionals need to attack each day’s tasks with an active focus. We cannot simply depend on a computer program to do the job for us. If all it took was a computer program, no thinking, no experience no effort—we would not be such a hot commodity in the world.
Editor’s note: Prescott is the CDI education director for ACDIS. She serves as a full-time instructor for its various Boot Camps as well as a subject matter expert for the association. Prescott is a frequent speaker on HCPro/ACDIS webinars and is the author of The Clinical Documentation Improvement Specialist’s Complete Training Guide and co-author on the forthcoming volume regarding the role of CDI staff in quality of care measures. Contact her at firstname.lastname@example.org. This article originally appeared in CDI Strategies.
Clinical documentation is the perfect practice area for me at this point in my career, because I utilize all of my past professional knowledge and experience on a daily basis. I am proud to be working in an area where the ultimate goal is achieving the highest quality documentation in each patient’s medical record when they access the healthcare system. Since I also love to teach, when I saw the job posting on the ACDIS website for a CDI Education Specialist and heard Brian Murphy encourage people to apply on the ACDIS Radio Show, I applied for the position.
I started down my healthcare career path back in late 1970s when I attended Michigan State University and earned a B.S. in dietetics. I was accepted into the Coordinated Undergraduate Program, completed clinical dietetics and foodservice management internships, and was able to take the registered dietitian (RD) exam shortly after graduation. I worked as a RD in a variety of healthcare settings, including hospitals (clinical and teaching positions), health departments (WIC, Maternal Support Services, Infant Support Services), and consulting firms. While working as a RD on teams with registered nurses, I began to see the narrow scope of working as a nutrition professional compared to the much wider scope of a nursing professional. I learned I wanted to help people in more areas of their lives than nutrition.
So, I decided to go back to school at Lansing Community College’s nursing program on an academic scholarship and graduated top of my class. Partly due to my extensive work with moms and babies as a dietitian, I then got a job in a Level 3 neonatal intensive care unit (NICU) at Henry Ford Hospital in Detroit. I have so many special memories from that experience.
In the ensuing years, I held various positions in healthcare, including management, case management (have been a certified case manager since 2010), utilization management, patient access, pharmacovigilance, subacute rehab/skilled nursing, consulting, and quality/core measures. I began working as a clinical documentation specialist (CDS) in January, 2011, back “home” at Henry Ford Hospital. Since then, I have worked at another large health system, the Detroit Medical Center, as a CDI specialist and have worked as a consulting CDI specialist for MedPartners. Satellite pictures I became a certified clinical documentation specialist (CCDS) in January 2013.
I never dreamed that I would be selected, but sometimes dreams do come true! I am so grateful for this amazing opportunity, for being part of this awesome CDI team, and I look forward to sharing my passion for clinical documentation with HCPro Boot Camp attendees across the country.
There are several people I have to thank for helping me get to this place in my career:
- My mom, Margaret—my number one fan.
- My daughter, Lynn, and my son, Ray, who were ages 7 and 5, respectively, when I returned to school to become a nurse. They’ve always been my cheerleaders.
- My husband, Felix, who said, “Go for it!” and “It’s YOUR time now” when I asked him what he thought about me applying for this position.
- My sister, Kate Upton, who has worked in healthcare as an administrator/executive for three decades, for listening and offering her highly intelligent, knowledgeable support and encouragement.
- My former managers and lifelong mentors, Dana Murphy and Patti Nemeth, and former coworker, Rita Ferrell, who dropped everything at a moment’s notice to discuss this wonderful opportunity and for encouraging me.
- Nancy Shows, B.S., RN, CCM, CCDS
ACDIS is pleased to welcome a new adjunct instructor to its CDI training team. Anny Pang Yuen, RHIA, CCS, CCDS, Corporate Director of CDI at the University of Pennsylvania Health System, and ACDIS Advisory Board member, will be joining us as an instructor for our ICD-10 for CDI and CDI Boot Camps. She will be co-teaching alongside our current instructors this summer so be sure to say hello if you’re in one of her sessions. Welcome Anny!
Q: Tell me a bit about your background in CDI?
A: Having served as a corporate director of CDI at Penn Medicine, I oversaw four hospitals and was successful in developing a unified and multidisciplinary corporate CDI process focused on improving physician/provider documentation and accurate CDI financial reporting. Prior to Penn, I was a manager at a consulting firm and assisted in many nationwide CDI implementations and re-invigorations. I also provided on-site CDI support to major health systems.
Q: Why did you decide to become a Boot Camp instructor?
A: I decided to become a Boot Camp instructor because I enjoy teaching and sharing my experiences with others. I also felt that this opportunity will allow me a chance to give back to an industry that I am passionate about. Furthermore, as a Boot Camp instructor, I will be able to use both my CDI and coding/compliance hats to help Boot Camp attendees gain a better understanding of the importance of documentation for clinical care and the level of specificity for coding and compliance.
Q: How do you feel your coding background will serve you as an instructor for CDI Boot Camps? [more]
We’ve had a number of calls recently asking us about our various CDI Boot Camp offerings. As you might guess, people are busy getting ready for ICD-10-CM/PCS implementation, and, between hiring new staff and reviewing ICD-10 opportunities, there’s a bit of a scramble going on for educational resources.
If you haven’t planned your training yet, here’s a list of where our Boot Camps will be over the next few months, and what you can hope to gain from each.
The next Physician Advisor’s Role in CDI Boot Camp takes place February 5-6 in San Diego. The two-day Boot Camp prepares physician advisors to successfully fulfill the duties of their job. They’ll walk away with a firm understanding of clarification opportunities in each Major Diagnostic Category, new techniques for engaging medical staff in CDI, and new avenues for CDI program growth.
It includes new ICD-10 documentation requirements and how to ensure full and accurate physician documentation to properly code records for ICD-10 as well as information on inpatient quality measures and the physician advisor’s role in Medicare Value-Based Purchasing.
The ICD-10 for CDI Boot Camp heads to sunny San Diego, California, December 8-10. The documentation issues that exist with ICD-9 will continue in ICD-10. The ICD-10 for CDI Boot Camp provides strategies that can be implemented immediately to improve documentation and facilitate a smooth transition to ICD-10-CM. ACDIS’ ICD-10 for CDI Boot Camp is the only training developed with CDI specialists in mind. Our instructors have in-the-field CDI experience and know exactly what CDI specialists need to know about the new coding system. You will get a CDI perspective on how to:
- Evaluate, revise, and focus physician educational efforts and queries to meet documentation requirements for ICD-10-CM
- Determine the impact ICD-10-PCS will have on the organization and whether CDI specialists should query for surgical procedures
- Highlight changes from the ICD-9-CM to ICD-10-CM Official Coding Guidelines so that CDI specialists can get coders the specificity needed
- Recognize how ICD-10-CM documentation requirements will affect principal diagnosis selection, additional diagnosis reporting, and diagnosis sequencing
- Identify solutions that will maximize efficiency and limit productivity losses during and after the transition
We’ll be in San Diego in December, Las Vegas in February, and Orlando in March. Won’t you join us? Click here to learn more about the ICD-10 for CDI Boot Camp or call us at 800-650-6787.