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Note from the Instructor: Is your CDI program stagnating? Get out of the rut and fast!

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Allen Frady, RN, BSN, CCDS, CCS, CRC

By Allen Frady, RN, BSN, CCDS, CCS, CRC

The basic tenant of learning CDI is learning how MS-DRGs work, and the tiered structure of CC and MCC levels. That is the first step, to be sure, but it is not the final destination. In the new era of quality based reimbursement, there are a number of growth opportunities. And yet, I believe many (if not most) CDI programs are either missing completely or performing poorly in meeting them. In the age of bundled DRGs, 30-day readmissions, hospital acquired conditions, Medicare Advantage Plans, patient safety indicators, quality reporting, and mortality rankings, if you find yourself having a harder and harder time justifying the value of proper documentation to your chief financial officer, take another look at the current state of affairs. [more]

Tip: The four E’s of staff education

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Brush up on some education tips and tricks!

by Amanda Southworth

Educating CDI staff and physicians alike can be a challenge. With busy schedules, resistant physicians, and a constantly changing healthcare environment, even the most seasoned educator can feel like pulling their hair out.

By keeping in mind four E’s, however, educating becomes a bit more manageable.

Efficient: Educational sessions should seek to get to the point quickly. With busy and fluid schedules, each educational session should have a focused point. Even if the timeframe incorporates a couple different subjects—say, clinical indicators and querying—each section still needs a point and direction. This will cut down on wasted time during your limited education space. [more]

Tip: Diversify your CDI education to keep staff engaged

Every CDI specialist knows how difficult it can be to set aside a whole hour or more for dedicated training and education. With productivity expectations and quotas, cutting out a sizable chunk of time for learning can be challenging. Diversifying CDI education tactics can help engage staff in more meaningful ways.

Though electronic health records (EHR) and technology sometimes complicate the CDI process in select ways, CDI managers and leaders can harness technology to increase educational reach. [more]

Website Tips: How to register for ACDIS Radio and never miss an episode again

According to the 2017 ACDIS Membership Survey, 73.68% of members find ACDIS Radio a beneficial piece of their membership experience. The bi-weekly talk show hosted by ACDIS Director Brian Murphy covers a wide-range of CDI-related news and topics through conversations with industry leaders, ACDIS Advisory Board members, physicians, CDI specialists, and managers. The show airs every other Wednesday at 11:30 a.m. eastern.

But, how do you access this free resource? While you can head over to the ACDIS website and listen to all the past episodes as soon as a day after they originally air, registering for the program makes things even easier. Plus, when you listen live, you can weigh in on the weekly poll and participate in the Q&A segment.

Simply follow the two step process below and you’ll get a weekly reminder when the show will air and instructions on how to tune in.

1. First, go to the ACDIS main page and select “ACDIS Radio” under the “Network & Events” tab (it’s the third option).

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2. Then, click the “register” button underneath the ACDIS Radio logo. The registration page will automatically open in a new window.

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3. Fill in the necessary information on the registration page and click “register” at the bottom of the page.

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4. Once you’ve clicked “register,” you’ll see a confirmation page with an option to add the program directly to your Outlook email calendar. All the instructions for listening to the call will be in the reminder emails for each episode.

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Editor’s note: To listen back to previous episodes of ACDIS Radio, click here. To read a recent Radio Recap about a session at the ACDIS Symposium: Outpatient CDI, click here.

Note from the ACDIS Editor: CDI Journal provides training tactics

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ACDIS Editor Linnea Archibald

By Linnea Archibald

New hire training. Ongoing education. Physician education. Each area holds unique difficulties for the CDI professional in all stages of their careers. Keeping all the CDI staff and physicians on the same page can be a daunting and headache-inducing task. For that reason, the July/August edition of the CDI Journal seeks to outline a few strategies, tips, and tricks from seasoned veterans in the field for keeping your whole team engaged and up-to-date in their CDI education.

Within the pages of the newest edition of the CDI Journal, you’ll find valuable information from a variety of perspectives—from CDI specialists conducting daily reviews, to CDI educators, to the ACDIS Advisory Board members, to the ACDIS leadership team and staff. [more]

Summer Reading: Physician Education Discussion Scenarios

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

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

The following clinical scenarios illustrate where clarification would be indicated and include examples of differing communication methods.

Clinical example: The record states the patient was admitted for treatment of pneumonia and the patient was placed on IV antibiotics. A swallow evaluation indicates the patient is at risk for aspiration. The patient is placed on aspiration precautions and thickened liquids. For the coder to assign a code for aspiration pneumonia, the relationship between the pneumonia and aspiration needs to be documented in the record.

Approach #1 (verbal query): “Dr. Smith, I’m Jane from the documentation improvement team. Do you have a minute to work with me? This chart indicates the patient is at risk for aspiration and needs thickened liquids. Could you identify a probable etiology for her pneumonia? The physician responds, “It is probably due to aspiration.” The CDI specialist thanks the physicians and asks, “Could you please clarify that possible cause-and-effect relationship in the record?” She then reminds the physician that “Unlike outpatient coding, the use of possible or probable is permitted and can be coded for inpatient cases.” The physician immediately writes an addendum to his progress note: “Jane, thanks for your help.”  Jane should then document this verbal query and the results as part of the CDI notes for this account. [more]

Behind the scenes at ACDIS: E-learning producer brings back industry-leading tips

Editor’s note: From time to time, we like to take a moment to share a behind-the-scenes look at what the ACDIS and broader HCPro team has been working on. Today, we wanted to shed some light on one of our e-learning producers, Amanda Southworth. Amanda recently attended the Association of Talent Development International Conference and Exposition (ADT) in Atlanta and brought back a number of important lessons about education, training, and e-learning. To see the complete list of HCPro’s e-learning opportunities, click here.

I recently had the privilege of attending the ADT, a massive four-day educational and networking event that included 10,000 learning and development professionals from all over the world. While there, I learned about the latest trends in the training world as well as the specific struggles, challenges, and successes specifically related to providing continuing education to those working in the healthcare field.

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Summer Reading: Stepping out on your own

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

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

‘Flying solo’

After a few trial runs, new CDI specialists should be given the opportunity to review records on their own. Before composing any queries during this initial stage, the manager or mentor should review a draft of the query proposed and provide feedback to identify any additional opportunities and compliance concerns, as well as to save the fledgling staff member from any potential physician ire due to a misplaced query.

Such feedback should reinforce concrete rules of the CDI road and should be supported by official rational from governing bodies such as AHA Coding Clinic for ICD-10-CM/PCS, Official Guidelines for Coding and Reporting, ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice, or in-house policies and procedures.  Of course, mentors and managers should offer their expert opinions and tips on how to practice effectively, as well. This feedback should also offer the new staff member an opportunity to voice questions and concerns, and accelerate the learning process. This step in the process can continue until the new staff member and the preceptor agree that the new CDI specialist is functioning well independently and is comfortable “flying solo.”

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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: Six steps to help you join the CDI ranks

Editor’s note: This article originally appeared on the ACDIS website in November 2015. To read the original article, click here.

There is a lot of discussion about how to be a good CDI specialist, but as the profession grows and facilities look to hire new CDI team members, many more people are looking to get into the field.

A few months ago, we received an email asking us what we would recommend to CDI hopefuls. After combing through our resources, consulting with our Boot Camp instructors and Advisory Board members, and interviewing working CDI specialists, here are six simple steps to help you set your feet on the CDI career path.

1. Learn as much as you can

When Shiloh A. Williams, MSN, RN, CCDS, CDI specialist (now CDI program manager) at El Centro Regional Medical Center in Holtville, California, initially applied for a CDI position, she knew nothing about CDI, coding, or the revenue cycle. She did a Google search before her interview and read up on DRGs, codes, and common diagnoses. Her research, coupled with her prior nursing experience and clinical knowledge, won her the position.

“I scoured the ACDIS website for information, ideas, and best practices,” Williams says. “Now that I’m doing the job, I am constantly turning to ACDIS resources for staffing and department metrics.”

Regardless of the field or position, any candidate who learns as much as possible about the role and company prior to sitting for an interview will have a distinct advantage. You may not have hands-on experience as a CDI specialist, but that doesn’t mean you can’t learn as much as possible about the field.

Review the materials on the ACDIS website—much of it is free—and take lots of notes. Read the ACDIS Blog and the CDI Strategies e-newsletter for timely tips and news updates. The ACDIS Helpful Resources page and ACDIS Radio are also fantastic free options to learn about the field and the industry.

It’s also a good idea to look through CDI job postings to see what facilities are looking for in terms of knowledge and experience. Some noteworthy topics to research include:

  • DRG basics
  • ICD-10 codes
  • How to read a medical record and research a chart
  • Hospital quality initiatives

2. Attend a local chapter meeting

If you have a local chapter in your area, call or email the leadership and ask if you can attend a meeting. This is a great opportunity to network with local CDI specialists, learn about the job from working professionals, and discuss timely topics and issues relevant to the field.

Networking may also lead to potential mentorship and job shadow opportunities that you wouldn’t have otherwise. Williams relied heavily on her mentors early in her CDI career.

“I was able to work alongside Marion Kruse, a well-known clinical documentation improvement and Medicare expert,” she says. “My passion for my work was fueled by her knowledge and expertise.”

Check the Local Chapter page on the ACDIS website for more information and meeting schedules.

3. Job shadow CDI staff

If you have a CDI program at your facility, ask the program staff if you can shadow them for a day to learn more about the work they do.

If your facility doesn’t have a CDI program, reach out to neighboring hospitals and see if their program would host you for a morning or afternoon.

Job shadowing is one of the most important things a prospective CDI specialist should do before applying for a job in the field, says Mark LeBlanc, RN, MBA, CCDS, director of CDI services at the Wilshire Group, and former ACDIS Advisory Board member.

“It’s a great opportunity to watch a CDI specialist work, ask questions, and see the work in action,” he says.

“It’s also a chance to see how you have to interact with staff on the floor. You need to be outgoing, and you have to be able to speak to all different levels of professionals, from providers to coders, so you can get things done.”

Also take advantage of other networking opportunities, such as reaching out to members of the ACDIS Advisory Board. “The board would definitely be willing to spend a few minutes with someone to talk about CDI,” LeBlanc says.

4. Analyze your skills

Typically, the most important attributes for a top-notch CDI specialist are extensive clinical knowledge and awareness of disease processes and complications, comorbid conditions, medical coding, and Medicare reimbursement.

A balance of clinical expertise and coding knowledge makes a candidate ideal, says Bonnie Epps, MSN, RN, CDI director at Emory Healthcare in Atlanta.

“I think [CDI] work would be easier if we all were proficient in coding,” says Epps. “If someone is interested in CDI, they should try and learn something about what coding is and why it’s important.”

Those with clinical backgrounds wishing to enter the field need to understand that CDI specialists have little to no contact with patients. Although their clinical acumen will definitely be put to use, they will no longer have any sway over the patients’ day-to-day care.

CDI work is based solely on what is written in the clinical documentation. For former bedside nurses, this requires a novel way of thinking and a willingness to learn new skills, Epps says.

“[An applicant] should be able to pick up the skills to read the chart, analyze the chart, and learn the coding rules and language,” says Epps. “You must be willing to learn these things and think in new ways.”

Communication skills (both written and verbal), imagination and creativity, and analytical and problem solving skills are also a must.

“You have to be willing to work with others and collaborate,” says Epps.

5. Train yourself

Programs typically train new CDI specialists for three to six months through in-house mentoring, job shadowing, and formal classroom learning. They often send new staff members to a CDI Boot Camp and/or have consulting training available.

However, if you are serious about getting a job in the field and want to expand your knowledge, it may be a good idea to sign up for an online learning program or a CDI Boot Camp on your own time. You’ll receive a comprehensive overview of the job and required knowledge, which will make you a more competitive applicant for prospective employers.

If you would like to work on training yourself, here are some helpful resources:

LeBlanc says prospective CDI specialists should also brush up on their anatomy and physiology— especially important with the advent of ICD-10.

6. Apply for the job

You’ve done the research. You’ve decided the job is a good fit for your personality and skill set. Maybe you’ve even job shadowed a CDI specialist or networked with CDI professionals at a local event. Now it’s time to apply for the job. There are plenty of facilities out there that will hire new staff even if they do not have CDI experience. Highlight any related training and skills in your resume and during interviews.

Keep in mind, you do not need to have the Certified Clinical Documentation Specialist (CCDS) credential to become a CDI specialist. The CCDS represents a mark of distinction for those who have been working in the field for a number of years. In fact, you must be a working CDI specialist for at least two years before you can sit for the exam. CDI career path.