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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.


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]

Coding for inpatient postoperative complications requires explicit documentation

Capture appropriate documentation for coding postoperative complications.

Determining when to code a post-surgical complication as opposed to simply considering it to be an expected outcome after surgery can be a complicated task.

A complication is “a condition that occurred after admission that, because of its presence with a specific principal diagnosis, would cause an increase in the length of stay by at least one day in at least 75% of the patients,” according to CMS.

Therefore documentation of a postoperative condition does not necessarily indicate that there is a link between the condition and the surgery, according to Audrey G. Howard, RHIA, senior consultant for 3M Health Information Systems in Atlanta, who will join Cheryl Manchenton, RN, BSN, an inpatient consultant for 3M Health Information System on Thursday, July 12, for a live audio conference “Inpatient Postoperative Complications: Resolve your facility’s documentation and coding concerns.”

For a condition to be considered a postoperative complication all of the following must be true:

  • It must be more than a routinely expected condition or occurrence, and there should be evidence that the provider was evaluating, monitoring, or treating the condition
  • There must be a cause and effect relationship between the care provided and the condition
  • Physician documentation must indicate that the condition is a complication

According to Coding Clinic, Third Quarter, 2009, p.5, “If the physician does not explicitly document whether the condition is a complication of the procedure, then the physician should be queried for clarification.”

Coding Clinic, First Quarter, 2011, pp. 13–14 further emphasizes this point and clarifies that it is the physician’s responsibility to distinguish a condition as a complication, stating that “only a physician can diagnose a condition, and the physician must explicitly document whether the condition is a complication.”

For example, a physician may document a “postoperative ileus,” but it is very common for a patient to have an ileus after surgery, Howard says. Therefore, this alone does not qualify as a postoperative complication.

“If nothing is being evaluated, monitored, [or] treated, increasing nursing care, or increasing the patient’s length of stay, I would not pick up that postop ileus as a secondary diagnosis even though it was documented by the physician,” Howard says.

Editor’s Note: This article first published on

To register for the July 12 program visit

Too many codes? There’s no such thing


The average person uses on 45,000 words.

by Michelle Leppert, CPC

A writer paints a picture with words. The English language alone offers somewhere in the neighborhood of a quarter of a million words. But really how many does the average person use? According to Stephen Pinker’s book “The Language Instinct” the average American high-school graduate knows approximately 45,000 words. That’s  a pretty big disparity, but it makes sense.

How many people do you know who use antidisestablishmentarianism in regular conversation? By the way, antidisestablishmentarianism is the longest non-technical and non-coined word in the English language (watching Jeopardy! pays).

Some other odd words that you’ve probably never heard of include:

  • Erinaceous (like a hedgehog)
  • Lamprophony (loudness and clarity of voice)
  • Depone (to testify under oath)
  • Finnimbrun (a trinket or knick-knack)
  • Floccinaucinihilipilification (estimation that something is valueless)
  • Inaniloquent (pertaining to idle talk)

So what does this have to do with coding in general and ICD-10-CM coding in particular? A coder tells a story with codes. Like any good storyteller, you want that story to be as complete and accurate as possible. ICD-10-CM’s increased specificity will help you do that.

A lot of people get hung up on the huge increase in the number of codes. ICD-9-CM includes 14,567 diagnosis codes, while ICD-10-CM offers 69,833. Big, scary difference, right? Yes and no. You’ll have a lot more choices, but that doesn’t mean you’ll use them.

How often does a patient come in for a spacecraft fire injuring occupant (V95.44) or for being bitten by an orca (W56.21)? For that matter, how many cases of light chain deposition disease or variant Creutzfeldt-Jakob disease or Pallister-Killian mosaic syndrome do you see?

If you code for a specialty, you’ll generally use a small fraction of the available codes. Even if you code for several specialties, you still won’t use every code.

And a lot of the codes are just more detailed. They aren’t new conditions or new diseases. For example, look at the codes for serous detachment of retinal pigment epithelium. ICD-9-CM offers one code choice—362.42. So you’re coding this condition now. The difference is when you get to ICD-10-CM, you’ll have four choices:

  • H35.721, serous detachment of retinal pigment epithelium, right eye
  • H35.722, serous detachment of retinal pigment epithelium, left eye
  • H35.723, serous detachment of retinal pigment epithelium, bilateral
  • H35.729, serous detachment of retinal pigment epithelium, unspecified eye

The additional specificity could be an unexpected aid as well. Because many ICD-10-CM codes include laterality, you shouldn’t have to worry that a payer will reject a claim because of double billing if you can code two separate sites (index finger and middle finger) or different sides of the body (right arm and left arm).

Don’t get stuck on the number of new codes. You don’t need to memorize them and you won’t have to relearn how to code diagnoses from scratch. Probably 90-95% of the coding guidelines remain the same. It’s a big change and will certainly be a challenge, but don’t be afraid of the choices.

Editor’s Note: This article originally published on the ICD-10 Trainer Blog.

Q&A: Communicating expectations to achieve excellence

Do you know what is expected of you? Do you have clearly communicated goals for how to grow professionally?

Editor’s Note: I recently came across this question and answer in one of our sister publications Nurse Leaders Weekly. In this instance the use of the word “quality” does not refer to a hospital’s quality assurance or quality indicator program but to the overall quality of a given effort. The question regarding how effective communication enables a program or department to advance its effectiveness and implement and achieve new goals for its staff applies not only to “nurse leaders” but leadership in every aspect of healthcare—CDI included.

I am sure that you have all had a particularly influential manager or someone you thought was a really great boss at one time or another. If you had that person in front of you now, what questions would you ask him or her? How did their communication skills help your awareness of your responsibilities?

Q: How does communication factor into the success of my quality improvement plan?

A: Good managers know that quality does not happen by fiat or executive order but is the result of staff members’ comprehensive understanding of what is expected of them, why it is appropriate to expect it, how they will be supported to deliver that performance, and how they will be evaluated according to defined criteria.

Communication is core to:

  • Defining the expectations of the organization for each employee’s performance
  • Clearly linking those expectations to the mission of the program and the larger organization
  • Outlining for employees how their individual and team performances are measured and evaluated, and keeping them informed of the results
  • Listening to employees’ thoughts and ideas about potential improvement, born of direct experience in delivering care and service
  • Sharing with employees the progress and knowledge developed elsewhere in the organization, and outside it, which may help employees improve individual and team performance

Conference Q&A: ‘The Art of Communication in CDI’

Colleen Stukenberg will present at the ACDIS Conference in San Diego.

Editor’s Note: Over the coming days and weeks, we will post a series of Q&As with presenters and participants from the 2012 ACDIS Conference in San Diego. The first in this series features Colleen Stukenberg, MSN, RN, CMSRN, CCDS, whose presentation “The Art of Communication in CDI and Beyond,” will take place on Thursday, May 10, 1:30-2:30 p.m.

Q: What core communication competencies should CDI professionals come to the role with?

A: While there are three main aspects I will address at the conference, I will add that professionalism, honesty, and respect for yourself and others are important traits for those working in the CDI role. These qualities will carry you far in life. If you do not have these in the CDI role, it can be difficult to communicate with others and earn their respect. You are working with other professionals with advanced education and they need to know that you are trustworthy and respectful. (You need to attend the session to hear my top three, though.)

Q: What communication talents can a CDI manager expect to be inherent and what elements can a manager help to instill in CDI team members?

Some characteristics are innate, meaning people are just born with certain talents. When interviewing a new CDI staff person, you only have a limited time to know whether this individual will be the right fit for the role. The person may act nervous in the interview but you should take note to observe how he/she interacts with you. Then have a team interview to see how he/she interacts with the team. You want someone that not only says he/she is a team player but also demonstrates it, as this is a team-player role. The CDI specialist will need to be able to interact clearly, honestly, and positively with various roles including physicians, nurses, and coders. Furthermore, the CDI specialist will need to be able to portray a professional positive attitude in meetings that may include administrative or board meetings.

Q: Can you name two or three common communication missteps that CDI professionals should be aware of?

A: Thinking too narrowly, thinking there is only one right answer, or thinking that the CDI specialist already “knows” the job. Education should never stop. We can learn from the expert and the novice. While we all have various roles, we ultimately are there to help improve patient care by promoting accurate documentation of the patient’s true clinical picture.

Q: What are you looking forward to most about this year’s ACDIS conference?

This is the first time I am speaking at the ACDIS conference and I am very excited. Attending the various sessions, activities, and networking with colleagues and the exhibitors are definitely on my agenda.  I am also looking forward to seeing all of the friends and acquaintances I have met over the past few years through ACDIS.

Diagnose first, admit second

Consider CDI collaboration with case management to target documentation concerns in the emergency department.

Among other tidbits in my background, I’m a recovering case manager.  It’s a hard, often thankless job, and it never ends.  I don’t think I could do it again, and I give lots of credit to those who still work in this field.  Nevertheless, I have had many occasions to interact with case managers in my previous role as a CDI specialist, and now, a CDI consultant.

As a recovering case manager, I often shied away from dealing with the CM department, but I’ve come to realize that not developing collaborative processes can be a huge mistake. When we avoid case management, we avoid the opportunity to build an ally. We both want medical records that reflect the optimum patient acuity, and that will survive RAC and other audits. And this process starts at the hospital’s front door.

Case managers review patients in the emergency department for admission criteria. If they know that chest pain and syncope and abdominal pain are RAC targets, and that documentation of diagnoses instead of symptoms may move the DRG out of the RAC crosshairs, they can communicate this to the physicians. I like to think of it this way: when the physician writes nothing of consequence, the CDI specialist looks for clinical findings and asks for the diagnosis, while the case manager asks for clinical findings and the treatment plan that support the medical necessity for the admission and strengthen the diagnosis that we just got.

It’s a symbiotic relationship.

I’ve had occasion to work with the case management team at a client hospital, and we decided to put our collective heads together to see how we could educate ED physicians not to admit patients who didn’t meet criteria. We chose as our slogan:  “Diagnose first, admit second!”

We created one page flyers to be posted in the ED and distributed to the ED physicians on popular topics such as chest pain and syncope.  In the flyers, we briefly gave suggestions of alternative diagnoses, defined what is needed to meet admission criteria, and encouraged physicians to consult with case management before writing that admit order.

At the same time, I’ve been presenting a weekly series of lectures to the case management department, very similar to what I would use to teach a new CDI specialist, but adding a little twist that ties clinical documentation improvement to case management.  It’s been a big hit.  They are eager to help teach physicians not to write “CHF” or “urosepsis,” and they want to learn more.  I’m going to give them all they can handle, including helping them read their PEPPER and use it to their best advantage.

Never assume that because someone doesn’t understand what you do, that they don’t want to understand what you do.  It’s like working with physicians and nurses; when you show them how your job relates to them and how it benefits everyone, you get more cooperation.  And as we used to say, cooperate and graduate.


Words to clarify by

Use these common phrases as clues for further investigation.

Many novice CDI specialists do not readily identify when a diagnosis needs clarification. The following list is intended to serve a gentle reminder to “dig deeper.” Here is a list of “clue” words to help you identify when a query may be needed for clarification or specificity.

AMS needs clarification as to possible Acute Confusional State, Alzheimer’s Dementia, or Alzheimer’s with Behavioral Disturbance. If with associated Infection, metabolic condition, etc. it could also indicate Encephalopathy.

Urosepsis could be UTI or Sepsis secondary to UTI.

Hypoxemia/Respiratory Insufficiency could indicate a diagnosis of Acute Respiratory Failure or Acute post Operative Respiratory Insufficiency if the indicators are present. (E.g. Use of C-pap or Non re-breather mask, or O2 saturation less than 92%).

Anemia requires specificity of Chronic Anemia, Acute Blood Loss Anemia, Aplastic Anemia, etc.

Renal insufficiency/chronic kidney disease (CKD) requires added specificity for the stage of the CKD, the Creatinine baseline and further specificity as to possible Acute Renal Failure (ARF), and if indicators present (E.g. nephrotoxic medication usage) ARF with Tubular Necrosis.

FTT, Anorexia may indicate Malnutrition. If present, further specify as to whether it is mild, moderate, or severe.

CHF requires specificity of acute or chronic and systolic or diastolic heart failure.

Right/left sided weakness may indicate a diagnosis of hemiplegia or hemiparesis.

Problems with speech post CVA may indicate a diagnosis of Aphasia.

Drug use History requires clarification of use or abuse and if the Drug Use/Abuse is Ongoing.

Abdominal pain requires documentation of an underlying diagnosis. (E.g. Ulcer, Acute Pancreatitis, etc)

Chest pain requires documentation of an underlying diagnosis. (E.g. CAD, Angina, Costochondritis, etc.)

Gangrene-requires further specificity as to “Wet” infectious or “Dry” ischemic Gangrene

Poorly controlled Diabetes needs clarification whether Uncontrolled or Controlled Diabetes Mellitus.

Hypertensive Emergency needs clarification as to Malignant or Accelerated Hypertension.

DVT needs clarification as to Deep Vein Thrombosis or Thrombophelbitis.

I&D needs clarification as to whether this means Irrigation and Drainage, Exisional Debridement or Non Exisional debridement. (If exisional debridement performed then documentation must state if scalpel was used, clear margins obtained, and depth up to and including deepest layer.)

↓↑Na is not a diagnosis. Documentation must be obtained as to possible Hyper/ Hyponatremia.

Reflections on physician leadership and engagement with CDI programs

Over the past several years there have been a number of conversations that touch on physician leadership involvement with CDI. Programs can and do achieve success, but so much more is achieved when there is a proactive and supportive medical voice.

Physician leadership can come from a number of sources and in a variety of forms. Some CDI programs (a few anyway) report directly or indirectly to a physician executive (medical staff functions, chief medical officer [CMO], etc.) and other programs report to the quality department where a physician executive is frequently directly involved. In these circumstances, I hope the physician executive maintains some amount of time dedicated for CDI efforts.

Some organizations are fortunate enough to have physician leadership within the broader organization that is (or have been convinced to be) very supportive to CDI efforts. From what I’ve heard, these frequently include CMOs and chiefs of staff and/or service lines within a given facility. Finally, some physicians, such as a medical director, physician champion, advisor, or liaison, devote a portion of their time to work directly with CDI. (Read more about the expanding roles and responsibilities of CDI physician advisors in the January 2012 edition of the CDI Journal.)

Furthermore, even with supportive medical staff leadership, how that support translates into action varies. Some facilities provide physicians time to offer educational sessions to their CDI and coding teams. Others provide CDI education sessions to entire physician groups by service line.

Most CDI programs earn physician leadership and support through the tireless efforts of the CDI staff and program leaders. Only occasionally have I seen this support present from the very beginning.

Some Perspectives

I’d like to look at the “state of affairs” in regards to physician leadership.  One ACDIS weekly online poll (2008) addressed the simple question of whether respondents had a “physician champion” and if that champion was effective. That poll was rather surprising; only 46% indicated they had a physician champion, and half of the respondents with a physician champion actually rated him/her as ineffective. So, according to that poll, only 23% of programs have an effective physician advisor.

ACDIS repeated the  poll (with slightly different wording) in April 2011 and though the results showed some improvement, they were still discouraging. In 2011, 31% described having a very beneficial physician champion, 22% described their physician champion as “’minimally effective”, 24% felt the position was not affordable, and 16% indicated that their program could not find a good candidate. Even more surprisingly to me, 7% said they simply did not see the need for the roll.

Additional polls from 2008 which echo the theme of limited physician support for CDI programs include:

Other recent poll responses illustrate different aspects of physician involvement in CDI , but I thought these painted an interesting picture.

Don’t forget the most recent study, published in the January CDI Journal, in which 73% (178 individuals) indicated that their physician advisor spends five hours or less dedicated to CDI efforts, and 54% described their advisor as either moderately effective or ineffective.


I think it is  important to have data to effectively measure any focus area of interest. I believe a couple of key metric data pieces provide insight to the level of success with physician engagement. In any analysis, I would include items such as:

  • Physician response rates
  • Severity of illness (SOI)/risk of mortality (ROM) data
  • Trends in volume of queries and more specifically the focus of queries (Do CDI staff ask the same queries repeatedly?)

I specifically would not include physician agreement rate except in a broader sense in looking for individual outlier physicians, to find those who either agree to whatever the CDI specialist asks or those who never agree with the premise of a CDI specialist’s query.

As always, I’d love to hear what elements other CDI programs use to statistically validate their physicians’ involvement with and support of their CDI programs.


Quite a bit of material is available between the ACDIS online polls (I have fun with those, obviously), various blog postings, journal articles, and conference presentations that offer useful information regarding physician engagement. Several provide inspiring examples of successes. Various items from other organizations are in the public domain.

If you are interested, shoot me an e-mail or leave a comment here and I can develop a partial list of links.

Wrap -up

I am sure most agree that fostering physician engagement in CDI efforts is one of the key challenges of every CDI program.

I certainly don’t have many great answers to this question, and I’d like to hear more thoughts, experiences, and success stories. I know some great examples would be wonderful Journal articles or blog posts.

I will toss in a final thought. Organizational cultural change typically takes five years. Certainly obtaining physician interest in documentation and coded data represents a significant cultural change.

Sometimes I wonder if just need to practice a little more persistence and a lot more patience.

Thankful for CDI community collaboration

Over this past year, I’ve had the tremendous honor and pleasure to engage in substantive conversations with at

Everyone has something to say, what can you learn by joining the conversation?

least three organizations. This has actually been a humbling experience for me — that ‘someone’ out there felt strongly enough of my knowledge, ability, experience, and/or writings that they sought my ideas on CDI. I know I learned a lot through the process of reflection and discussion that occurred. I feel I gained so much more than I offered.

This ‘jazzed’ feeling I experienced during those conversations is the same that I’ve felt every time I’ve been able to attend a gathering of CDI professionals, every time I’ve had the opportunity to speak and teach about CDI or documentation, every time I’ve had a reflective exchange on CDI Talk, or every time I’ve enjoyed any sort of stimulating conversation.

Seems to me, these opportunities I’ve enjoyed are part of the broad concept of networking and collegial professional relationships. This is one of the strongest characteristics I feel we possess as a nascent profession — collaboration, mutual support, and exchange.

This is an important avenue for us as we advance our professionalism.

I am deeply grateful that I’ve had a variety of such experiences. I hope that many others have had the honor to feel this excited about (and due to) our CDI profession. Equally, I wish for everyone a coming year filled with professional satisfaction and fulfillment.