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Note from the CCDS Coordinator: Over the Y92.838 and through the Y92.821 to Grandmother’s Y92.01 we go


CCDS Coordinator Penny Richards

By Penny Richards

Ah. Thanksgiving. While the ACDIS team will be out of the office for the Thanksgiving holiday and Black Friday, we know that the opportunities for mishaps requiring medical attention are far too plentiful to mention. We wouldn’t want to leave you without ACDIS’ guidance in this trying time, so here is a short list of codes that might prove helpful to the on-duty clinical documentation specialist. [more]

Guest post: Compliance risks abound in HCCs

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Let’s discuss the compliance risks CDI and coding professionals need to address related with hierarchical condition categories related to the MACRA.

Coding must be based on provider documentation, not what is entered on a superbill or computer software. ICD-10-CM code assignment is based solely on a provider’s documentation in the legal medical record, according to the 2017 ICD-10-CM Official Guidelines and Coding Clinic, Fourth Quarter, 2016, pp. 147–149. The problem is that many physicians document one way in their notes and then pick an ICD-10-CM code in their billing software or superbill that would not be assigned if one applies ICD-10-CM coding conventions based on the provider’s documentation.  [more]

Guest post: Keep up with coding compliance for physicians facing MACRA changes

James S. Kennedy, MD, CCS, CDIP

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

What’s a physician’s favorite radio station? When it comes to coding compliance and revenue cycle management of their practices, WII-FM, What’s In It For Me, is what physicians listen to.

Physician salaries have traditionally been based on CPT-driven relative value units in a fee-for-service environment, meaning the more that the physician did, the more he or she got paid. As a result, many physicians diminished their understanding or application of ICD-10-CM diagnosis coding because, most of the time, these don’t affect physician reimbursement unless it is to determine medical necessity for a procedure they want to perform. [more]

Note from the instructor: Reminiscing over 10 years in CDI


Sharme Brodie, RN, CCDS

By Sharme Brodie, RN, CCDS

One of the wonderful things that time allows us is the ability to look back with an experienced eye and either learn from the past or at the very least have some fun with it.

I remember my first weeks as a CDI specialist as if it just happened. It was a  grueling hiring process and I was thrilled to have gotten the job. Looking back, I have no idea why I thought this would be a good step in my career. None of us knew at that time what we were doing and we had no idea what to expect from this new profession. [more]

Note from the Associate Director: Symposium lookback and a preview of things to come


Rebecca Hendren

By Rebecca Hendren

Two weeks ago we held our inaugural ACDIS Symposium: Outpatient CDI in the intimate setting of a suburban Chicago hotel. The hotel was surrounded by a beautiful golf course, where the first golden colors of autumn were beginning to emerge on the trees, and the setting made us feel somewhat cut off from the rest of the world as we spent two days discussing the new frontier in CDI.

We had sessions focused on practical issues, such as building compliant queries in the outpatient setting, and we had sessions from organizations that have established outpatient programs, where the speakers shared how they do it and their lessons learned along the way.

But the most fun parts were the times that we had open discussions. It was fascinating to hear everyone talking together and sharing ideas and thoughts. We all learned a lot and people made connections to lean on as they develop their outpatient programs. [more]

Q&A: Receiving query responses from providers

Have CDI questions?

Have CDI questions?

Q: Our hospital is having a hard time getting our physicians to respond to queries, do you have any suggestions on how to get them to reply?

A: The most important thing is make sure the query is concise and contains clinical indicators from the record. You also want to use different methods of contacting the physician as well. Various points of contact include within the electronic health record, via e-mail, by phone, or by having your CDI team visit them on the floor. [more]