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Q&A: Coding guidelines for COPD and pneumonia

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 sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.

 

Conference Q&A: Manchenton digs into surgical CDI

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Cheryl M. Manchenton, RN, BSN, CCDS

Editor’s Note: Over the coming weeks, we’ll take some time to introduce members to a few of this year’s ACDIS conference speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we talked with Cheryl M. Manchenton, RN, BSN, CCDS, senior inpatient consultant/project manager with 3M Health Information Systems, overseeing CDI programs, who will present “Anatomy of an Operative Note: A CSI Analysis of Operative Notes Gone Bad.” Manchenton specializes in workflow design, program management, quality metrics, and performance. She is responsible for the 3M quality services and quality services training materials and hosts the 3M CDI Management Roundtable. Manchenton is a guest for ACDIS Radio on the March 22 at 11:30 a.m. EST. She will be providing a brief preview of her conference presentation that you won’t want to miss! To register for ACDIS Radio, click here.

Q: What’s the biggest challenge you encountered in your experience with surgical CDI programs?

A: The biggest challenge is lack of timely operative notes or detailed daily progress notes. In other words, minimal documentation by surgeons including a comprehensive list of chronic conditions.

Q: What are three things attendees can expect from your session?

A: Our session will be at minimum entertaining. Attendees can expect us to share very common pitfalls with operative note templates, strategies for collaborating to improve and results of effective collaboration.

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: Instead of complaining about who’s fault something is with poor documentation, coding or quality metrics, I hope our session will show attendees some creative ways to actually improve.

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

A: Collaboration!

Q: Fun question: What is your favorite animal and why?

A: I love otters. They work hard but play hard too. They know how to make work fun.

 

Conference Q&A: Faustino shares her remote CDI experiences

Lara Faustino

Lara Faustino, RN, BSN, CCDS

Editor’s note: So we’re getting close to conference time!  we’ll take some time to introduce members to a few of this year’s speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we caught up with Lara Faustino, RN, BSN, CCDS, a CDI s specialist at Boston Medical Center (BMC), who will present “A Visibly Invisible CDI Team.” She has 10 years of clinical experience in three large, academic medical centers in New England and extensive knowledge in both CDI and quality enterprises. During her career, Faustino developed best practice provider education for documentation, helped with her facility’s EMR transition, and developed training strategies and tools for the ICD-10 transition. Additionally, she was nominated by peers to the Massachusetts Regional Leadership Co-Chair status (2016) and served as the national 2015 BMC representative at the ACDIS national conference.

 

Q: How does your remote CDI position give you a unique perspective on the field as a whole?

A: I believe as technology advances, specifically the integration of the electronic health record (EHR) and tele health, I view a new angle on healthcare delivery (not just the field of CDI) as a whole. As the future state of virtual physical assessment evolves using iPads/iPhones from a remote setting, a successful CDI program will adapt to the same methods of communication to enhance the physician relationship.

 

Q: What are three things attendees can expect from your session?

A: Attendees can expect to learn about decisions that prompted the program to go remote; how to identify key strategies that support the success of a remote CDI Program; and the work/life balance.

 

Q: What one tool can CDI professionals not live without?

A: Specifically, from a remote CDI perspective, an excellent internet connection to an electronic health record!

 

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: My session will challenge CDI professionals to think outside the “walls” of a hospital setting – self-discipline, autonomy, and confidence and how to maintain harmony will all be discussed.

 

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

A: Networking! I always enjoy learning from a variety of CDI professionals from across the nation and it always amazes me how very similar we are, or how vastly different we approach the same types of challenges.

 

Q: Fun question: Do you have pets and if so, what are their names?

A: I do! I have a dynamic duo of dogs that keep my days exciting (my office mates!). Their names are Max (Beagle) and Oliver (Golden Retriever), but we call them “Ham & Cheese!”

 

Conference Q&A: Haik offers a clinical perspective on sepsis and respiratory failure

haikEditor Note: Over the coming weeks, we’ll take some time to introduce members to a few of this year’s ACDIS conference speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we’ve reached out to William E. Haik, M.D., F.C.C.P., C.D.I.P., who has practiced medicine in Fort Walton Beach, Florida since 1980, and will be presenting “Sepsis: 1, 2, 3 – RAC Attack! Respiratory Failure: Definition and Sequencing Guidelines.” He has received board certification in internal, pulmonary, and critical care medicine. Dr. Haik’s past professional accomplishments include: Chief of Internal Medicine, Director of Respiratory Care Services, Board of Trustees at his local hospital, President of the Okaloosa County Medical Society, and representative of the Government Liaison Committee for the American College of Chest Physicians. Dr. Haik’s coding background has included AHA’s Editorial Advisory Board and Expert Advisory Panel of Coding Clinic for ICD-9-CM as well as participation in the preparation of the original AHIMA CCS and CDIP examinations. He served on the original Board for ACDIS and aided in the preparation of the first certification examination. He currently serves as a final arbitrator for Medicare Part C MS-DRG modifications and as an expert consultant to the United States Department of Justice. He served on a multi-disciplinary committee which developed the 2010 and 2013 AHIMA Physician Query Practice Brief. Dr. Haik has conducted educational seminars and national teleconferences regarding physician involvement in DRG management, coding, and other related topics in association with HCFA (CMS), AHA, AHIMA, HCPro, and various state Quality Improvement Organizations. Since 1988, Dr. Haik has served as the Director of DRG Review, Inc., a physician directed hospital coding consultative service. The goal of DRG Review, Inc. is to educate medical and coding staffs in medical record documentation and coding compliance.

Q: As an MD, what do you bring to the CDI table that others don’t?

A: I think I bring a practical knowledge, a working clinical practice perspective. I have some coding knowledge as well, so I can merge the two.

Q: What are three things attendees can expect from your session?

A: Complete boredom! Just kidding! In all seriousness, attendees can expect to:

  1. Understand the clinical definition and coding nuances of acute and chronic respiratory failure;
  2. Understand the evolution of the definition of sepsis; and
  3. Understand how to apply the three different sepsis consensus statements and how, by understanding those, one can defend an adverse clinical documentation position from a RAC

Q: What is one tool CDI professionals cannot live without?

A: In my opinion, a CDI professional should have a few things in their toolkit. First, they should have a clinical background, a working knowledge of the coding clinics for ICD-10, a reference tool that answers certain clinical guide and their coding correlation.

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: We do arm wrestling during my talk! Just kidding. In reality, I’m trying to get them to think inside the box! I want to get everyone to think clinically as a physician would.

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

A: It is in Las Vegas, need I say more? Seriously, though, I’m looking forward to hearing some presentations on quality – HCCs, VBP – such as that. I’m really looking forward to expanding my knowledge.

Q: Fun question: do you have any pets?

A: Her name is Mary-Kate – she’s my wife. Just kidding. Actually, I don’t have any pets right now. I have had three dogs, though. They were named Bitey, Gus, and Tucker.

Conference Q&A: DeVault illuminates the shift to outpatient CDI

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Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA

Editor’s Note: Over the coming weeks, we’ll introduce a few of this year’s speakers who are heading to the podium for the ACDIS 10th Annual Conference which takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we talked with Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA, manager, HIM Consulting Services for United Audit Systems, Inc., who presents “Clinical Documentation Improvement – From Inpatient to Outpatient: Defining the different documentation, coding, and reimbursement requirements.” She has more than 25 years of experience in HIM serving as the senior director of HIM practice excellence, coding and reimbursement for AHIMA from 2008 to 2014.

Q: What made your company want to expand into the outpatient setting?

A: We noticed that it was the next natural progression in the CDI world. With hierarchical condition categories (HCCs), Medicare Access and CHIP Reauthorization Act (MACRA), risk adjustment, etc., it’s really a prime time for CDI. Where to start is the hard part. With inpatient documentation reviews, CDI professionals have a captive audience, so to speak. With outpatient, CDI programs need to look at all the different departments where physician documentation plays a role. On top of that, there’s the physician clinics. It’s very complex on how you move the well-oiled machine of inpatient CDI into the outpatient world – everything gets really muddied.

Q: What are three things attendees can expect from your session?

A: At the end of my session, attendees will be able to:

  1. Start to delineate what outpatient CDI looks like in the post-acute care setting. It’s not as simple as duplicating your inpatient CDI program
  2. How inpatient and outpatient CDI roles differ; and
  3. Some tools to build the framework for outpatient CDI. Your CDI framework could look very different and you need to do active discovery. CDI looks different in every setting based on where their needs are.

Q: Who should attend your presentation and why?

A: CDI specialists and anyone who’s involved with coding and CDI – CDI managers, finance side, directors, HIM directors, coding managers, coders, and even physicians! Essentially, it would be good for everybody. Anybody trying to figure out what outpatient CDI looks like should definitely attend. It’s like the transition to ICD-10 in that we need to think about how we eat the elephant one bite at a time. Outpatient CDI is a whole new elephant.

Q: What’s one tool no CDI professional should be without?

A: A CDI specialist should always have their communication skills. A CDI specialist is in a unique position because they live in the middle. They need to have a relationship with providers and then they also need that communication with coders.

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

A: Networking! Last year, was the first year I was there as a vendor. It’s so fun to meet our clients. It’s great to put a face to a name!

Q: Fun question: what’s your favorite movie?

A: I’m kind of a sap, so I love PS. I Love you. I also really love Brian’s Song.

 

 

 

Conference Q&A: Ericson sheds light on alternative payment models

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Cheryl Ericson, MS, RN, CCDS, CDIP

Editor’s note: Over the coming weeks leading up to the conference, we’ll take some time to introduce members to a few of this year’s speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. For today’s Q&A, we caught up with Cheryl Ericson, MS, RN, CCDS, CDIP, the manager of clinical documentation services with DHG Healthcare, who will present “Leveraging CDI to Improve Performance under Alternative Payment Model Methodology.” Ericson is recognized as a CDI subject matter expert for her body of work which includes many speaking engagements and publications for a variety of industry associations. She currently serves on the advisory board for ACDIS and its credentialing committee (CCDS).

Q: Could you tell me a bit about what makes Alternative Payment Models (APM) different for CDI?

A: Participation in voluntary APMs is very complex and requires a high level of commitment from the healthcare organization. More than 800 hospitals, however, are required to participate in the Comprehensive Care for Joint Replacement Model (CJR) and an additional 1,100 or more hospitals will be required to participate in the episode payment for AMI and coronary artery bypass grafts (CABG). Because participation is based on randomly selected Metropolitan Statistical Areas (MSAs) many hospitals may be unprepared for the impact. These models are retrospective so the hospital is paid as usual under the applicable MS-DRG, but following the completion of the performance year the hospital may be required to return some of their payment to Medicare or they may receive an additional payment. This type of model, like many of the outcome measures included in the mandatory value-based methodologies, require CDI specialists to look beyond the current episode of care. The mandatory quality programs, however, only use a 30-day timeframe. In comparison, an episode of care in the APMs extends 90 days beyond hospital discharge or the date of surgery.

Q: What are three things attendees can expect from your session?

A: Attendees can expect to learn:

  1. The difference between the mandatory value-based programs such as HVBP, HRRP, HACRP, and mandatory APMs
  2. A better understanding of the mandatory bundled/episode based payment methodologies
  3. Strategies to incorporate into the CDI process to accurately reflect organizational performance under the mandatory bundled/episode payment methodology

Q: What is one tool CDI professionals cannot live without?

A: A grouper that supports risk-adjustment efforts.

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: As the fee-for-service population decreases, which was reliant on CC and MCC capture, CDI specialists need to understand and modify their efforts to reflect modern CMS reimbursement strategies to support organizational financial health.

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

A: Like most, I enjoy reconnecting with friends. I have the added bonus of reconnecting with former ACDIS Boot Camp participants. It’s great to learn how people have advanced in their career as the CDI profession continues to grow!

Q: Fun question: What is your favorite candy?

A: Dove Promises dark chocolate with almonds. Yum!

 

Conference Q&A: Hirsch offers insight into CDI utilization review contributions

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Ronald Hirsch, MD

Editor’s Note: Over the comings weeks, we’ll take some time to introduce members to a few of this year’s ACDIS conference speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada.  Today, we’ve reached out to Ronald Hirsch, MD, FACP, CHCQM-PHYADV, vice president of the regulations and education group at AccretivePAS Clinical Solutions, who will present “Medicare Regulation Update: Practical Application for CDI Professionals.” Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians and serves on the Advisory Board of the American College of Physician Advisors. He is the co-author of The Hospital Guide to Contemporary Utilization Review, published in 2015.

Q: What’s the biggest challenge you’ve encountered related to implementing Medicare regulations?
A:
Regulations and guidance from CMS are often vague and occasionally contradictory. These regulations affect everyone, including the doctor, the patient, the bedside nurse, the case managers, CDI staff, the billing and coding staff, and the C-suite (those working in upper administrative roles). Understanding the regulations and implementing them compliantly across the many affected groups is a challenge for hospitals.

Q: What are three things attendees can expect from your session?
A:
Let me just list some of these out:

  1. To hear a simple explanation of the two-midnight rule
  2. To understand the practical application of medical necessity guidelines for CDI professionals
  3. To be familiarized with the required patient notifications

Q: What is one tool CDI professionals cannot live without?
A: If they learn the two-midnight rule as I teach it, they will become the hero of their institution.

Q: In what ways does your session challenge CDI professionals to think outside the box?
A: CDI professionals work hand in hand with case managers but often do not understand their work. Gaining an understanding of that work makes them a more indispensable part of the team.

Q: What are you most looking forward to about this year’s conference?
A: As a physician advisor expert, my CDI knowledge is quite cursory. With the breadth of courses available at the conference. I expect to walk out with a much deeper understanding of CDI. I can’t wait for the pre-conference Boot Camp for physician advisors. It will be an honor to hear from Erica Remer, MD, and James Kennedy, MD, two of the most renowned physicians in CDI.

Q: Fun question: Do you have any pets?
A:
My wife and I just got a new kitten three weeks ago. Leopold is a little wild thing during the day between naps but he loves to cuddle with us at night in bed.

Q&A: Mentioning SOI/ROM and support level of care in queries

Have a question you'd like ACDIS experts to answer? E-mail mvarnavas@cdiassociation.com

Have a question you’d like ACDIS experts to answer? Comment below!

Q: Is the statement “please document in a progress note to capture the severity of illness (SOI), risk of mortality (ROM) and care needed for this patient” appropriate to use in a query? In general, is it appropriate to mention SOI/ROM and support level of care and profiling when querying physicians?
A: Many mature CDI departments know that providers respond better to discussions regarding the SOI/ROM than they do regarding reimbursement (i.e., discussions of dollars). Most providers feel they treat the “sickest of the sickest” and pointing out how their documentation affects quality measures and reporting illustrates the direct benefit of CDI efforts for them and their patients.

However, it is important to have discussions with providers explaining the relationship between documentation, reimbursement, healthcare quality, profiling, etc. CDI staff should share information regarding the importance of SOI/ ROM during formal training sessions with the medical staff and as the opportunity arises during impromptu interactions with individual providers on the hospital floors.

I subscribe to the concept of keeping the query as concise and simple as possible. Therefore, I would not include this type of language you provided as part of the query process itself.

As an additional note of caution, since the MS-DRG and APR-DRG reimbursement systems are based on the “severity” of the patient’s condition—the more “severe” the patient’s condition, presumably, the higher the reimbursement—providers may associate the discussion with a secret code of sorts. “When I say SOI/ROM, you know I’m really addressing reimbursement.”

The 2013 query practice brief, Guidelines for Achieving a Compliant Query Practice Brief states:

“A query should include the clinical indicators…and should not indicate the impact on reimbursement.”

Consider circling back to a provider if he or she fails to respond to a query and explain why the query was placed and how a change in documentation could have positively affected reimbursement, healthcare quality, profiling, etc., reinforcing the initial education provided. Physicians often respond to concrete examples. When such is associated with their own documentation, even better. Timing such discussions and including additional illustrations of both effective and deficient documentation to prove your point helps take the emphasis off a specific situation which may be deemed leading and places it within the realm of overall program goals and general documentation improvement.

Also, I always encourage CDI specialists to trust your gut. If it feels a little murky to you, then don’t do it. Nothing is worth compromising your integrity and ethics.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, Associate Director for Education at ACDIS and CDI Education Director at HCPro in Danvers, Mass responded to this question.

Q&A: Identifying the principal diagnosis

Do you have a CDI-related question? Leave us a comment below.

Do you have a CDI-related question? Leave us a comment below.

Q: A patient came to the emergency department with shortness of breath.  The admitting diagnosis was possible acute coronary syndrome (ACS) due to shortness of breath (SOB) and elevated troponin levels. The ACS was ruled out. Elevated troponin levels were assumed to be due to chronic renal failure (CRF), and no reason was given for SOB. Before discharge, the patient was noted with an elevated temperature and found to have a urinary tract infection (UTI). All treatment was directed at the UTI, and the doctor noted the discharge diagnosis as the UTI. What would be the principal diagnosis in this case?

A: Without knowing all the specifics, and reading how it was presented, I would say the UTI could not be taken as the principal diagnosis. For the UTI to be the principal diagnosis, we would need to query for two pieces of information.

  1. The first issue would be whether or not the UTI was present on admission. From this description, it does not was appear to have been not present on admission, but the symptoms appeared before discharge.
  2. The second concern would be to determine whether the UTI was somehow linked to the patient’s presenting symptoms. A UTI and SOB is a difficult connection to make.

If we eliminate the UTI as a choice, even if the majority of treatment was directed towards to the UTI, we have little to work with. I would query for the probable or likely cause of the SOB. If the provider answers with a definitive diagnosis then this would be your principal diagnosis. If not, the symptom of SOB would be your principal diagnosis.

The bigger concern with this patient might be that the wrong status was assigned. This patient most likely should have remained outpatient and placed in observation status until a more definitive diagnosis could be found warranting an inpatient admission.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her atlprescott@hcpro.com. For information regarding CDI Boot Camps visitwww.hcprobootcamps.com/courses/10040/overview.

 

2015 Conference Preview: Q&A with Karen Bridgeman

Do you know what sessions you’ll attend? The 2015 conference will be held in San Antonio, Texas.

Do you know what sessions you’ll attend? The 2015 conference will be held in San Antonio, Texas.

Editor’s Note: The annual conference is right around the corner, and we’ve got dozens of presentations in store. If you haven’t started planning your itinerary, we’ll preview a handful of speakers throughout the coming weeks to give you a feel for the sessions. This week, we spoke with Karen Bridgeman, MSN, RN, CCDS, who, along with Tina H. Smith, BSN, RN, CCDS, will present “Through the Looking Glass: Examining APR-DRGs in the Pediatric Population.”

Q: Why is pediatrics becoming an important component of CDI programs?

A: The MS-DRG, developed for reimbursement for the adult Medicare population, does not adequately meet the needs of the pediatric population. However, the APR-DRG was developed to meet some of the unique needs of the pediatric population. It also provides organizations the means to evaluate and compare quality measures. Medicaid insures more than 31 million children, including roughly half of all low-income children in the United States. As more and more state Medicaid programs use the APR-DRG system for reimbursement, CDI specialists need to understand how the APR-DRG system differs from the MS-DRG and how those differences affect their pediatric record reviews. 

Q: How is your topic important for everyone in the CDI role, regardless of professional background?

A: CDI specialists, coders, and physicians need to understand the importance of clinical documentation, not just on reimbursement, but how documentation affects quality metrics. Physician and hospital quality metrics are driven by the severity of illness and risk of mortality, captured by the APR-DRG ranking system so it’s important that we accurately capture specific diagnoses in the medical record. CDI programs can help improve a hospitals’ mortality index with improved capture of secondary diagnoses.

Q: As an RN, how does your perspective differ from other professionals performing the CDI role?

A: I bring my clinical knowledge into my reviews along with my confidence as a nurse in educating the physicians. Our coders often seek out our CDI nurses to verify their findings or seek clarification of the medical record. Having a good relationship with coders is essential. We rely on each other for expertise, mine in my clinical knowledge and theirs in the coding guidelines. We learn from each other.

Q: What do you think is the most important quality for a CDI professional to have?

A: Being able to take the initiative is probably the most important quality. Working independently, asking “why,” and seeking answers is essential for the CDI role. You must understand the clinical diagnosis and the pathophysiology, as that will help you look for secondary diagnoses, query opportunities, and provide a better understanding of the patient’s condition.

Q: Why do you think attending the ACDIS conference is important?

A: CDI specialists have limited resources to further our knowledge. We are a small niche, and relatively new profession. The wealth of knowledge shared at the conferences is invigorating, the speakers experts in their field, willing to sharing their knowledge and experiences. But, attending the ACDIS conference is more than listening to the speakers—it’s also about the networking, informal sharing of knowledge and practices. It’s fun to catch up with other CDI specialists that you only see at the conferences, listening to all the great experts, networking with other CDI staff, seeing some ‘old’ friends, and having some fun.