BS, RHIA, RHIT, CCS, CDIP, CCDS,

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1 cdijournal January 2014 Vol. 8 No. 1 Director s Note 5 ICD-10 will take center stage at May conference. Dual coding 6 Coding for ICD-10 now highlights areas for physician education and concurrent CDI opportunities. Staff retention 8 Programs put bonus models in place to keep staff engaged through ICD-10 implementation. Homegrown training 10 Comprehensive efforts lead to new team member success. Staff goals 12 Sample goals for new CDI staff outline expectations from three months to two years. EHR efforts 14 Three specialists share their EHR implementation experiences. Meet a member 16 Christina Raad, RN, CCDS, receives her certification. Physician corner 17 Trey La Charité, MD, discusses how CDI helps prevent auditor denials. Clinical corner 20 Richard Pinson, MD, FACP, CCS, revisits respiratory failure documentation. Survey results 24 Get the breakdown on how programs are preparing for the ICD-10 transition. Review queries for ICD-10 focus, compliance The results of a December ACDIS survey show the CDI profession toddling toward the ICD-10-CM/PCS transition, says founding ACDIS advisory board member Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, AHIMA-approved ICD-10-CM/PCS trainer and HIM professional in Fremont, Calif. (See p. 24 for the complete survey results.) People seem to be getting there, but they re taking baby steps. That s good, but now we really need to be getting ready to jog and run, she says. Twelve percent of survey respondents indicated they received no information to raise their awareness of ICD-10-CM/PCS documentation improvement needs. Only 68% said they received training on the code set, and 32% indicated their CDI staff assists with ICD-10-related education for physicians. Those who haven t had any training whatsoever need to move ahead, start with an orientation or awareness of ICD-10 code set, Bryant says. One of the simplest ways to do that is to evaluate your queries and audit them for ICD- 10-CM/PCS opportunities. And the good news, according to the survey results, is that many programs have already started doing so. First steps Fifty-eight percent of survey respondents indicated they had reviewed their queries for type and frequency as of December This is a great first step, Bryant says. According to the survey, facilities typically use templates for the following queries (read the complete list of query templates on p. 25): Heart failure: 96% Sepsis: 91% Anemia: 90% Malnutrition: 88% Renal failure: 84%»» Respiratory failure: 82% Although only 37% of respondents indicated that they have begun reviewing their forms for ICD-10-CM/PCS documentation specificity, another 29% indicated that they will begin doing

2 so during the first quarter of I would like to have seen the percentage of programs revising their queries for ICD-10 to be a bit higher, says Bryant. The more we focus now, the more we will learn about where potential documentation gaps may be. The sooner we incorporate those areas into our query efforts, the better off we ll be in terms of ensuring a smooth transition to the new code set. People [need to be] looking at what their documentation is today and how that should influence their actions in relation to the ICD-10-CM/PCS implementation, says former ACDIS advisory board member Shelia Bullock, RN, BSN, MBA, CCM, CCDS, CDI director at the University of Mississippi Medical Center (UMMC) in Jackson. Once you take a good hard look at it, you ll see which items are really worth worrying about. While many facilities have contracted with consultants or outside auditing companies to conduct a documentation gap analysis, this isn t strictly necessary, and individual CDI specialists can make progress, says Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA, vice president of HIM consulting services for United Audit Systems, Inc., in Cincinnati, an AHIMA-approved ICD-10-CM/PCS trainer. Even a lone CDI specialist with the most limited of training budgets can, at the very simplest level, order an ICD-10- CM coding manual and look up codes while dropping a query to see what the definitions say, to identify areas where additional documentation will be needed, Stanfill suggests. Alternatively, set aside time to pick a manageable percentage of records and review them Fridays for ICD-10 opportunities, she says. Have the entire team participate and review all the different types of records, says Stanfill, not just the top DRGs. You want to be sure that everyone gains hands-on experience with documentation needed for the new code set across various topic areas not just the codes that result in a CC/ MCC, but all the floors and all the specialties, so you re not blind-sided during implementation, she says. Walk through policies to ensure compliance ICD-10-CM/PCS hasn t been the only new CDI program focus in recent years. Everything from electronic health Advisory Board ACDIS Director: Brian Murphy bmurphy@cdiassociation.com Associate Director: Melissa Varnavas mvarnavas@cdiassociation.com Membership Services Specialist: Penny Richards, CPC prichards@cdiassociation.com Dee Banet, RN, BSN, CCDS Director of CDI Norton Healthcare Louisville, Ky. dee.banet@nortonhealthcare.org Susan Belley, MEd, RHIA, CPHQ Project Manager 3M HIS Consulting Services Atlanta, Ga. sebelley@mmm.com Timothy N. Brundage, MD, CCDS Physician Champion Kindred Hospital North Florida District St. Petersburg, Fla. DrBrundage@gmail.com Donald Butler, RN, BSN CDI Manager Vidant Medical Center Greenville, N.C. dbutler@vidanthealth.com Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-Approved ICD-10-CM/ PCS Trainer CDI Education Director HCPro Danvers, Mass. cericson@hcpro.com Robert S. Gold, MD CEO DCBA, Inc. Atlanta, Ga. DCBAInc@cs.com Sylvia Hoffman, RN, CCDS, CCDI, CDIP President, CEO Sylvia Hoffman CDI Consulting Tampa, Fla. sylvia@sylviahossman.com Walter Houlihan, MBA, RHIA, CCS Baystate Health Springfield, Mass. walter.houlihan@baystatehealth.org Fran Jurcak, RN, MSN, CCDS Director, CDI Practice Huron Healthcare Chicago, Ill. fjurcak@huronconsultinggroup.com Trey La Charité, MD Physician Advisor University of Tennessee at Knoxville Knoxville, Tenn. Clachari@UTMCK.edu James E. Vance, MD, MBA CEO Physician Executive Management Services, LLC Highlands, N.C. jevancemd@physicianexecutiveservices.com Donna D. Wilson, RHIA, CCS, CCDS Senior Director Compliance Concepts, Inc. dwilson@ccius.com Previous ACDIS board members: Cindy Basham, MHA, MSCCS, BSN, CPC, CCS ( ) Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS ( ) Shelia Bullock, RN, BSN, MBA, CCM, CCDS ( ) Jean S. Clark, RHIA ( ) Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS ( ) Garri Garrison, RN, CPUR, CPC, CMC ( ) Colleen Garry, RN, BS ( ) Robert S. Gold, MD ( ) William E. Haik, MD, FCCP ( ) Tamara Hicks, RN, BSN, CCS, CCDS ( ) Robin R. Holmes, RN, MSN ( ) James S. Kennedy, MD, CCS ( ) Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, CCDS ( ) Pam Lovell, MBA, RN ( ) Gail B. Marini, RN, MM, CCS, LNC ( ) Shannon E. McCall, CCS, CCS-P, CPC, CEMC, CPC-I, CCDS ( ) Lynne Spryszak, RN, CPC, CCDS (founding member) Colleen Stukenberg, MSN, RN, CMSRN, CCDS ( ) Heather Taillon, RHIA ( ) Lena N. Wilson, MHI, RHIA, CCS, CCDS ( ) CDI Journal (ISSN: ) is published quarterly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA Subscription rate: $165/year for membership to the Association of Clinical Documentation Improvement Specialists. Postmaster: Send address changes to CDI Journal, P.O. Box 3049, Peabody, MA Copyright 2014 HCPro, a division of BLR. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, a division of BLR, or the Copyright Clearance Center at Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call or fax For renewal or subscription information, call customer service at , fax , or customerservice@hcpro.com. Visit our website at Occasionally, we make our subscriber list available to selected companies/ vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of CDI Journal. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. 2 January HCPro, a division of BLR.

3 record implementation, Medicare reimbursement changes such as hospital value-based purchasing, and quality reporting metrics have become front-burner topics and led to a shift in some traditionally held CDI conceptions. CDI programs that are solely financially focused may need to make some adjustments, Bryant says. The change to ICD-10 is about expanding our ability to capture clinical data, to improve the data quality we have in this country, she says. There is going to be a host of reasons to expand the purpose of CDI query efforts, such as severity of illness, risk of mortality, and for research purposes; programs need to be ready for that. CDI programs should already be reviewing their query forms/templates on a regular basis, as recommended in AHIMA s 2008 practice brief Managing an Effective Query Process, says Laurie L. Prescott, MSN, RN, CCDS, CDIP, CDI education specialist for HCPro in Danvers, Mass. Those facilities which already had such practices in place most likely responded positively to December s survey. Although the practice brief does not specify the frequency of such reviews or the composition of the committee(s) who should review them, annual or biannual auditing helps for two reasons, according to Prescott: compliance with industry recommendations and incorporation of the most up-to-date clinical indicators. Ensuring query forms comply with the latest CDIrelated industry recommendations is important. For example, the 2013 ACDIS/AHIMA practice brief Guidelines for Achieving a Compliant Query Practice updates previous AHIMA releases in light of the forthcoming shift to the new ICD-10-CM/PCS code set. The brief outlines ways in which so-called yes/no queries can be compliantly drafted and describes use of multiplechoice queries. Yes/no queries can be useful in ICD-10-CM coding by establishing a cause-and-effect relationship necessary to assign combination codes, writes Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA approved ICD-10-CM/PCS trainer and CDI education director at HCPro, in the book The Clinical Documentation Improvement Specialist s Guide to ICD-10. At Swedish Medical Center in Seattle, Jennifer Woodworth, RN, BSN, CCDS, director of CDI, and her team reviewed their standard query formats reducing their templates to just four or five ways in which we can ask the physician a question in order to ensure compliance, she says. They also created easy step-by-step formats for queries related to linking diagnoses, such as complications due to diabetes, and contemplated the problem of unlinking diagnoses as well. We know that linking one causal diagnosis to another will be a concern withthe new code set, says Woodworth, and we want to be sure to capture that information. Yet we have to be aware of situations where the two diagnoses really do not go together, and we need to know how to ask that question without second-guessing the physician s clinical judgment. Reassessing query forms for ICD-10-CM/PCS isn t just about adding the right verbiage to the forms, she says; it s also about rethinking the query process. The word template means different things to different people. For us, it really meant taking a look at what the most recent query practice brief indicates and incorporating the additional underlying elements of the new code set. Really, this isn t just a matter of adding some language here and there but updating our process, retooling our efforts, says Woodworth. Having a multidisciplinary team vet query forms helps to ensure compliance related to a broad range of concerns clinical validity, regulatory compliance, and coding accuracy. Regular query template reviews should be done by the CDI and the coding staff with input from the compliance officer or the compliance committee, says Prescott. Although 54% of survey respondents indicated that their compliance department does not review new/updated query forms, Bryant says such input is warranted. That [survey] result is sort of surprising considering the emphasis of the various [ACDIS and AHIMA] query practice briefs on compliance concerns. So this is an area for CDI programs to improve, particularly in light of the work required in revising query forms for ICD-10-CM/PCS, Bryant says. Additionally, regular reviews of templates with input from the CDI program s physician advisor and/or facility medical staff can help to ensure forms reflect the most recent clinical indicators, such as updates from the Surviving Sepsis campaign, and recommendations published in the May 2012 Journal of the Academy of Nutrition and 2014 HCPro, a division of BLR. January

4 Dietetics regarding diagnosing malnutrition. The CDI team needs to ensure that queries are accurate and up to date with latest standards of practice, Prescott says, and this is where a multidisciplinary team including a physician advisor s involvement would be useful. Nevertheless, 61% of survey respondents indicated that their physicians did not review any new or updated queries. In a related poll on the ACDIS website ( msgy854), only 13% indicated that a multidisciplinary team defines which clinical standards should be used as general query definitions for a given diagnosis. We really need to get back to the physician connection to CDI efforts, says Bryant, not only because that connection is highly recommended in the industry, but because we know that when physicians are involved in the process, involved in helping to create the query forms, they tend to support it. Expectations for productivity Numerous speakers at the AHIMA conference in Atlanta in October addressed projected coder productivity losses, with estimates ranging from 20% to 60%. In Canada, coder productivity dropped by 50% after the country s initial 2001 transition to ICD-10, said Elaine O Bleness, MBA, RHIA, CHP, AHIMA-approved ICD-10-CM/PCS trainer and revenue cycle executive for Cerner Corporation in North Kansas City, Mo. Coder productivity has since only rebounded to approximately 80% of pre-icd-10 levels. Consider, also, that Canada did not have to deal with the procedure portion of the code set so the U.S. may be in for an even bigger productivity decline. Why the slowdown? In part, since ICD-10 codes use both numbers and letters, coders can no longer just use the keypad to type in codes, said O Bleness. But coding also takes longer due to the greater analytical skills required from the coder and the additional documentation needed from the physician. According to the new coding guidelines for PCS, the hospital cannot submit a bill unless all the characters within that code are complete. With that came an expectation that coders would spend 50% more time on these cases alone, says Paul Weygandt, MD, JD, MPH, MBA, CPE, vice president of physician services at J.A. Thomas and Associates, Inc., a Nuance company. That s one reason many believe that procedure documentation could be an area ripe for regulatory review and intervention (denials). We were scared to death about the procedure coding system until we started looking at the codes and the documentation requirements, says Bullock. After careful review, Bullock s team found that many of the documentation needs associated with ICD-10-PCS could be resolved with simple amendments to either surgical templates or physician order forms. For example, UMMC updated its cardiology templates to include the type of contrast and number and location of vessels used, all of which will reduce the number of queries needed later in the process. At Swedish Medical Center, Woodworth and her team developed a template that identifies which type of stent the physician used during an angioplasty. They also amended documentation templates to identify cemented versus noncemented hip replacement procedures to avoid the need for queries. We are taking a look at what procedures our different specialty lines are doing day in and day out, says Woodworth. We re looking to see what additional documentation is going to be needed, and then seeing what solutions we can come up with to capture that information in a relatively easy, noninvasive way, using the tools the physicians currently use, she says. It s a different solution set but one we think will actually solve the problem and keep us from having to query for every little thing. Despite the anticipated increase in coder workload associated with ICD-10-PCS, Weygandt says much of the documentation may already be in the record or could be obtained through simple template adjustments. Part of the challenge of ICD-10 reviews is identifying which items represent actual CDI focus areas and which require a focus on coder theory and education, Weygandt says. There s been a panic mentality, particularly in regards to PCS, he says, but I don t think we really need to panic. We simply need to get on with the process, apply ICD- 10-PCS to the types of cases relevant to each hospital, and identify the opportunities to improve documentation and coding. 4 January HCPro, a division of BLR.

5 Director s note What happens at ACDIS Las Vegas stays in Vegas except for the learning You ve probably heard the expression What happens in Las Vegas stays in Las Vegas. That s true of our upcoming annual conference at Bally s Hotel in May. I encourage you to let your hair down and have fun while you re at Bally s on the strip it s what Vegas is all about! But I can promise you that you re also going to learn a lot about CDI in three days, vital information that you can take back and share with your colleagues or your medical staff. We ve got another great conference lined up in 2014, and I thought I d take a few moments to share just some of the session highlights: Inpatient psychiatry. A large percentage of patients entering the hospital have some sort of mental illness, depression being the most common. CDI staff can emphasize the importance of having the physician and staff nurse document accordingly and accurately to improve patient outcomes. This session will identify opportunities related to borderline personality disorder and describe the impact of ICD-10 comorbid conditions related to mental health. CDI in the ED. This session will detail how Stony Brook Medicine designed a CDI program for its emergency department with a focus on quality and capturing present on admission indicators. It will also explain how the effort required more than just physician engagement and support. Practical solutions and best practices based on experience of starts and stops will be offered. Obstetrics. This session is focused on the obstetrics service line, little explored and often misunderstood. Most obstetrics patients are not Medicare, but many opportunities for improved APR billing/coding exist in this population. Participants will leave able to identify frequently missed secondary diagnoses, recognize common documentation pitfalls, define good obstetrics documentation habits, and measure outcomes to ensure success. Focus on ICD-10. As we highlight in a number of the articles in this edition of CDI Journal, October 1 is looming larger and larger, and the ACDIS conference is the place to come to get prepared for the deadline. We re offering nearly two full days of ICD- 10 education, including a general session by Nelly Leon-Chisen, executive editor of AHA Coding Clinic for ICD-10 the authoritative source on the new code set. Focus your efforts by learning about the top 20 ICD-10 documentation issues that cause DRG changes. Pre-conference reception. This is Vegas, after all, so this year we ve added our first pre-conference networking session to get everyone started in fine evening style. Join us the night before the conference for an evening welcome reception, complete with a complimentary drink and appetizers, and get the networking started together with your peers at the nation s only conference dedicated to CDI. I hope to see you in May, and remember what happens in Vegas stays in Vegas. Except for what you learn. That will power you through another full year and get your CDI program recharged for success. Take care, Brian D. Murphy, CPC bmurphy@cdiassociation.com , Ext HCPro, a division of BLR. January

6 ICD-10-CM/PCS Implementation year begins with dual coding Has your coding department begun dual coding ICD-9 and ICD-10-CM/PCS? If your answer is no, or if you don t know when your facility plans to start dual coding, you could be already behind the curve. According to a December 2013 poll on the ACDIS website ( 45% of respondents expected their facility to begin dual coding in January, and another 17% indicated they expect to begin in April. If you have one New Year s resolution, make it dual coding, says Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA, vice president of HIM consulting services for United Audit Systems, Inc., in Cincinnati, and AHIMAapproved ICD-10-CM/PCS trainer. Why? Because you cannot improve on an unknown, says Paul Weygandt, MD, JD, MPH, MBA, CPE, vice president of physician services at J.A. Thomas and Associates, Inc., a Nuance company. You need to do an assessment today. If you don t, then you are not going to have any idea how you will perform under ICD-10. You need to do an assessment today. If you don t, then you are not going to have any idea how you will do with ICD-10. Paul Weygandt, MD, JD, MPH, MBA, CPE Yet every facility differs, Stanfill says, and every program s transition plans need to reflect not only the priorities of the hospital but also the program s CDI and coding focus areas. We may think that everyone has already started dual coding, but in reality some are starting January 1 and others are waiting to start in March or April, she says. Other facilities are planning to use contracted or consulting staff to code a percentage of records using ICD-9-CM, freeing up internal coders to practice reviewing records for ICD-10-CM/PCS. As an example, Stanfill cites one facility that used a consulting firm to gradually take on more and more of the facility s ICD-9-CM coding over the course of By the October 1 ICD-10 implementation, the firm will be coding 100% of the ICD-9 records. Those types of plans and the rates of records reviewed will be very particular to a facility s needs and where they are in their implementation strategies, she says. The value of dual coding comes from the practical application of the code set and the lessons learned in advance of the go-live date, says Stanfill. It may sound basic, but you have to see whether the coders know how to apply the new code set, to see where existing efforts are. If the coders have received training and yet are not comfortable using the code set or aren t using it accurately, you have time to iron that out, but if you don t start looking at it now you won t have time to work through those kinks during go-live, she says. Study shows coding accuracy improvements needed An October 2013 report from the Health Information and Management Systems Society (HIMSS) and the Workgroup for Electronic Data Interchange (WEDI) tested coders efficiency in the new code set. The report concluded that even though the volunteer coders were AHIMA-approved ICD-10 trainers from various facilities, they had an average accuracy rate of just 63%. (See the full report at Anecdotally, Stanfill relates the experiences of one facility, which provided online ICD-10-CM/PCS training to its staff and then handed them records to code. They didn t know how to do it, she says. The facility had to hire additional trainers to come in and provide extra education. During the second round of training, you could see the light bulbs going off all over the room, she says. If you start now, there will be plenty of time to circle back and provide extra education later on for the trouble spots. Most errors in the HIMSS/WEDI test were functional [ones], according to the report, such as case numbers not matching up appropriately or mistakes made due to other administrative errors. However, the study also highlighted some interesting 6 January HCPro, a division of BLR.

7 areas for potential targeted improvement. The study took redacted records and grouped them in waves. In the pilot, the term wave was used to mean scheduled phases in which each set of medical test cases were sent to each of the participating organizations. Each wave could contain upwards of 10 or more clinical scenarios. For example, scenario 19 in wave 1 was for a case related to ICD-9 code , diabetes with renal manifestations, Type 2 or unspecified type, not stated as uncontrolled; this scenario had an accuracy rate of 38%. Scenario 73 in wave 11 related to ICD-9 code 486, pneumonia only, and had an accuracy rate of 58%. (View the coding efficiency rates and their example medical records online at These were real clinical scenarios, says Rhonda Taller, BA, MHA, principal consultant for Siemens Healthcare, who was involved in the report s creation and worked with the study group that organized the program during a December 2013 Talk Ten Tuesday podcast. Working through actual medical records to test coder effectiveness is a vital piece of program preparedness, says Mark Lott, principal of Lott QA Group, who is conducting national testing of the new code set. You need to go over your own records and see how many times the coders get the right answers across all records, says Lott, who also spoke during the Talk Ten Tuesday session. Canned scenarios are not optimal training tools, he says. And don t rely on the general equivalency mapping systems, or GEMs, to do the work for you. You need to make sure that coders are using the codes the right way, not just mapping the codes, Lott says. Highlight skill sets to solve concerns When coding and CDI teams work together, they can optimize their practice by figuring out how ICD-10-CM/ PCS challenges will fit with certain skill sets, says Weygandt. If coders cannot code due to gaps in physician documentation, and if they need to query the physician retrospectively to resolve those gaps, several negative effects could occur among them delays in discharged/not final billed cases, as well as additional declines in productivity due to the increase in retrospective queries, says Stanfill. We need to be helping the physicians improve their documentation, not simply increasing the number of queries they need to answer, says founding ACDIS advisory board member Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, AHIMA-approved ICD-10-CM/PCS trainer and HIM professional in Fremont, Calif. Other challenges will specifically relate to coding theory, such as inpatient infant circumcision, where despite clear documentation, ambiguity related to the application of ICD- 10 procedural coding principles could arise, says Weygandt. So facilities will need to identify those concerns also. Swedish Health Services in Seattle began reviewing records for ICD-10-CM documentation improvement opportunities in the final months of 2013, according to Jennifer Woodworth, RN, BSN, CCDS, director of CDI. We really wanted to make sure that we had query templates ready for the common [CDI-related] concerns, and that we clarified what documentation coders already had at their fingertips, Woodworth says. Just as coders are dual coding, CDI specialists need to start dual reviews, Stanfill says, examining the record not only for documentation improvement opportunities needed in ICD-9 but also in anticipation of those that will be needed for ICD-10-CM/PCS. As each team makes new discoveries, they will need to share the lessons they ve learned. An October 2013 report shows that coders from various facilities had an average ICD-10-CM coding accuracy rate of just 63%. Nearly 75% of respondents to a December 2013 ACDIS ICD-10 survey indicated that CDI specialists meet with coders regularly, and that most of those respondents 30% meet monthly (read the report on p. 24). Bryant calls the 25% which do not meet with coding staff disappointing and hopes that the two teams will increase meetings and collaboration in light of the ICD-10-CM/ PCS challenge. As you learn, you ll update your queries, refocus, and adjust your processes, Stanfill says. CDI is a key solution to the ICD-10 transition and a critical enabler to challenges related to the implementation. The CDI song, in terms of ICD-10 implementation, is the same song the coders are learning, it s just a different verse HCPro, a division of BLR. January

8 Bonus structures help programs retain staff through ICD-10 There is no doubt about it CDI specialists will be taking on more work and a greater complexity related to that work in 2014 due to the implementation of ICD-10. The question for many CDI managers around the country is: How do I keep my staff intact, given that they re facing a greater workload, competing pressures, and increased career opportunities from other facilities and consulting firms looking to hire? I know my staff is juggling responsibilities and doing so much more than simple chart reviews, says Samantha Joy, one Illinois-based CDI director whose name has been changed at the request of her facility. Joy took over the program two years ago and grew its staff by 50%. She now has 12 full-time CDI specialists. One has been working at Joy s facility for eight years; the newest staff member started a few months ago. There are no plans to hire additional staff members due to the ICD-10-CM/ PCS implementation. Although Joy hasn t had any trouble with staffing turnover in the past, and salaries are in line with the ranges reported in her area (read the 2013 Salary Survey results in the October edition of the CDI Journal), she understands how valuable CDI expertise will be in 2014 and wants to be ahead of the curve. So when her facility s ICD-10-CM/PCS steering committee began discussing retention bonuses for coding staff, Joy began researching similar trends in the industry for her staff as well. She found only a few facilities who had developed retention bonuses for CDI staff, but that was enough to convince her it was a good idea. So she drafted a proposal, and received approval in December. According to the proposal, CDI specialists will receive an incentive payment for remaining on as staff, staggered and delivered in the following increments: 25% of the incentive payment once they start their ICD- 10-CM/PCS training 25% of the payment once they complete their training, based on an 85% or higher proved competency rate 50% of the payment one year post-icd-10 implementation If these staff members leave the facility for any reason. they will have to pay back the money they ve received; and, of course, they must remain in good standing while on staff, completing their regular workload and performing their duties as appropriate, says Joy. Training is expected to begin early in 2014 and take about four or five months to complete. CDI specialists will also review the components of physician training so they understand what physicians have learned and have the ability to fill in the gaps if necessary. The question is how to reward my staff for taking on all this additional information, and how can I retain them once I ve trained them, says Joy. There are not a lot of facilities doing this yet either that or they haven t thought through to this level of planning so far. So I feel like I am just one more step ahead. Joy may be ahead of the game, but she s not alone. Peacehealth System in Oregon has given some thought to retention bonuses as well. In fact, it started doling them out back in We are trying to encourage the staff that is here with us already to stay with us, says Juanita Carriveau, RN, CCDS, director of clinical documentation integrity for the system. ICD-10-CM/PCS is going to require a lot of extra training, time, work. Once we train our staff, we really can t afford to lose them, adds Janice Schoonhoven, RN, MSN, CCDS, CDI manager for Peacehealth s West Network. It behooves us to not just stick our heads in the sand here. The bonuses which are a set, flat dollar amount are distributed in June and are contingent upon staff members successful completion of their ICD-10-CM/PCS training. Remediation will be provided for staff who do not successfully navigate the training, but in the end all staff members will be required to pass a competency evaluation to remain involved in CDI. This must be done by a specific date, which Peacehealth CDI department has yet to set. Peacehealth s CDI staff includes 32 full-time employees at five facilities; 15% of them are near retirement age (59.5 years old), so she is also looking into job-sharing strategies and other measures to keep those staff members engaged and on board. 8 January HCPro, a division of BLR.

9 You need to think about what you can do for those who are near the retirement age, she says. Work-from-home arrangements are possible for facilities which have made the transition to a full electronic health record, but PeaceHealth won t be fully electronic until 2016, Carriveau says. If we can hold onto those senior people who maybe still love their jobs but don t want to work full time, it could really help us through this transition, she says. Retention bonuses and job sharing aren t the only items being scrutinized by Peacehealth administration when it comes to staffing preparedness for ICD-10-CM/PCS implementation. Carriveau recently instigated the realignment of her CDI staff s pay scale to coincide with the area s nursing staff since the team is made up entirely of nurses. We wanted to eliminate that discrepancy between union and nonunion workers, she says. If we looked at our salaries compared to a bedside nurse s, we were asking people to take a cut in pay to become a CDI specialist. Nobody wants to do that and it doesn t send the message that we want them to hear. We want them to know they are valuable members of the Peacehealth team. Carriveau also worries about drops in CDI and coder productivity with the advent of ICD-10; she anticipates a need for a 20% 50% increase in staff. Coders at Peacehealth began dual coding in December (see the related article on p. 6) and were impressed by the additional documentation necessary to code even routine procedures, she says. So that means CDI professionals have to be on board to get that missing information into the documentation before it gets to the coders, Carriveau says. We need to start querying related to ICD-10 and get up to speed on the documentation needs, says Schoonhoven. We need to be as strong as possible in our efforts. Add in rumors of CMS reimbursement delays of 30, 60, or even 90 days, and any delay in discharged/not final billed claims becomes an additional fiscal burden that facilities may not be able to withstand, Carriveau says. You re talking about a lot of money for hospitals all across the country, she says. Hospitals with CDI programs will be looking for additional staffing, and those without programs will either be looking to start them or looking to hire consulting firms to do the work for them. With an already limited supply of experienced CDI professionals to pull from, and consulting and staffing firms actively recruiting from hospitals CDI teams flexible work times, job assignments geared to experience levels, competitive pay and bonus incentives are needed for successful recruitment and retention as programs move into I-10. Hospitals have long been incentivizing physicians due to the provider shortages, and now this is lapping over into the CDI nursing realm. Schoonhoven says her staff seems pleased with the promises of bonuses, especially in light of the nation s overall economic hardship. Everyone has been through cut after cut after cut, in staffing she says, so being in a group that is getting something is huge, and it sends a message to the staff that they are valued. And then there are the intangibles, the soft benefits, Schoonhoven adds. As examples, she points to the system s strong identity and inclusive mission, her team s camaraderie, and staff members love of the CDI role. We have a lot of those, and they are definitely worth a lot. We put a lot of energy into considering what we love about our jobs and ensuring that our staff are both challenged and supported. Illustrated by David Harbaugh Doctor, this is Gretchen in records. Your documentation reads like the Declaration of Independence from compliance HCPro, a division of BLR. January

10 CDI training Collaborative approach works best when new staff start In October 2013, when Lead Clinical Documentation Specialist Rebekah Foster, RN, CCDS, hired four new staff members (three full-time and one part-time) at Kaweah Delta Medical Center in Visalia, Calif., she anticipated starting their training by enrolling them in ACDIS CDI Boot Camp. Unfortunately, the class sold out and the next open session wasn t until November. Foster started to panic. I was nervous about how well I would explain what I know. I worried about whether I would be a good teacher, she says. But necessity is the mother of invention and so, pressed to do the best she could for her new team, Foster began gathering educational items into a binder. While she worked, she kept in mind all the lessons she had learned along the way since starting in her role two years ago as well as all the lessons she hadn t been taught. When I started, we had two weeks of training from a consultant and then we were sort of on our own, Foster says. When I started thinking about training my own staff, I wanted to be sure I included items that I would have liked to have learned, too. Since she hired nurses from her own facility, the new staff members were familiar with the general concept of CDI and already knew many of the physicians. But since they were coming fresh from bedside nursing, they needed to learn to see the medical record from an entirely different perspective as a tool for coding, data mining, and reimbursement. In her binder, Foster covered the basics by giving definitions for the foundational terms of the job, such as queries, DRGs, and CCs/MCCs. For the first week, she sat with her new hires daily. Anything I found useful from my own experiences, I pulled in, she says. Together, they covered computer program basics, reviewed PowerPoint presentations used to train physicians, and spent a day with the coding staff. The new specialists shadowed Foster as she reviewed records and were free to ask questions during the process. At the end of the first month, the new specialists shadowed other team members one on one, rotating between team members to gain an awareness of each CDI specialist s various technique and style. On Fridays the team, now consisting of seven CDI staff members serving a 400-plus-bed acute care facility, sat together and talked about the review process. Foster also met with her new employees to review the week s lessons and reinforce key concepts. The poor guys were inundated, she says. They were all shocked by how much information there was to learn. They were amazed that the job wasn t just about reviewing records and talking to physicians. When the group finally got a chance to participate in the CDI Boot Camp, Foster attended also. It turned out to be good that we waited a few weeks before attending the Boot Camp. They were a little more familiar with the information and had an opportunity to see the process in the flesh, so they got more out of it. Even I was amazed by how much there was to learn, she says. Set learning goals for CDI growth Northern Westchester Hospital in Mount Kisco, N.Y., recently hired two new CDI nurses. Kerry Seekircher, RN, CCDS, documentation specialist supervisor there, followed a training path similar to Foster s by using her own experiences as an overarching guide. The 233-bed facility hired a consultant who came in and trained the three-person team for two weeks, providing an overview of CC/MCC basics, DRG definitions, and coding guideline lessons. Meanwhile, Seekircher pulled information from materials on the ACDIS website, downloaded items from the Forms & Tools Library, and incorporated various AHIMA physician query practice briefs into her own training material handbook. She crafted query exercises, compliance quizzes, and learning objectives for the team, She also outlined a series of goals, which defined what the new staff members should expect to understand at the three-month, 10 January HCPro, a division of BLR.

11 six-month, one-year, and two-year marks. (Read the sample goals, which you can adapt to your facility s needs, on pp ) Coming from bedside nursing, and coming from multiple years of clinical experience, there is a desire to feel reliable in the role, a need to feel like you can immediately do everything and understand everything, Seekircher says. But that simply isn t a realistic expectation for a new CDI specialist. You cannot be at the two-year mark when you ve only been in the role for three months. Such an outline of expectations was long overdue, she adds. I know that we are going to need additional training resources as time goes on. We need to illustrate those goals and set timelines associated with them in order to make sure the resources are available to help us meet those goals. Now three months into their roles, the new staff members have begun querying on their own. The hardest thing for me was not receiving that instant gratification from the physicians, says Sarah Thomas, RN, BSN, one of the new team members. Physicians typically respond quickly to nurses concerns on the floor after all, a patient s life may depend on it, Thomas says. In comparison, although responding to queries is still important, it is urgent, not emergent, she says. Kathleen Foley, RN, one of the new CDI specialists, was previously in a nurse manager role and has 18 years of nursing experience. She watched her previous hospital implement the CDI program and saw it grow. Yet it s really different from what you expect once you get into it, Foley says. Every day we re learning something new. It s both a challenge and a blessing. Plan training to incorporate learning styles The situation at Westchester and Kaweah Delta is similar to events taking place throughout the country, says Laurie L. Prescott, MSN, RN, CCDS, CDIP, CDI education specialist for HCPro in Danvers, Mass. When Prescott started in the role, she received training from a consulting company and was then immediately sent out to conduct reviews. The first time I looked at a chart, I had no idea what I was looking for, says Prescott. I had no idea how to decide what information was important. I ve done a lot of things in my life, but coming into the CDI profession was one of the steepest learning curves I ve ever encountered. Now, as one of the lead CDI Boot Camp instructors, Prescott encounters many new professionals and tries to make their educational experience a positive one. The first piece of advice she reserves for CDI program managers? Hire appropriately, she says. It isn t about whether you know X or Y or Z, Prescott says, but whether you have the right personality for the job. CDI specialists can come from nursing backgrounds or they may come from case management, coding, or HIM, she says. Because there is no CDI school and new staff members need years of on-the-job experience, there will always be a need to train them on one aspect of the role or another. The role of CDI specialist is best filled by an individual who is outgoing, positive, eager to learn, and confident enough to communicate the important facets of what he or she knows to others, says Prescott. Finding someone with enough self-confidence to let you know what they don t know is so important in this role, too, she says. When training new hires, managers need to understand a person s strengths and weaknesses and work to establish the best learning strategies for him or her. Don t make assumptions about what an individual may know, Prescott warns. For example, she once hired a former case manager to the CDI role, assuming that the person would be knowledgeable about the clinical picture of the patient. Yet once in the role, the new staff member required additional training on the particular clinical indicators relevant to the CDI processes. So with that in mind, it s important to conduct an assessment of the individual s skill set against the expectations of the position, says Prescott. If the new staff member comes from a nursing background, he or she will likely require additional training on the revenue cycle and coding basics. If the new staff member comes from coding or HIM, he or she may need more information about how to approach physicians and how to interpret clinical indicators in a concurrent manner. Once you ve hired and assessed the individual, you need to lay the groundwork for his or her training. For example, when Prescott started she had no idea what a CC or MCC was, so when such terms were used without explanation during her formal training, she immediately felt lost HCPro, a division of BLR. January

12 At a recent ICD-10 for CDI Boot Camp, Prescott taught a woman who had been on the job for only three days. I tried to make sure I came back to her frequently during the breaks to explain any of the key concepts she missed during the lectures, but I knew that there was so much information she was missing because of the advanced nature of the program, she says. So Prescott spoke with her manager and helped craft follow-up training sessions; she also discussed the possibility of retaking the course online in a few months as a way to review the information. Prescott suggests that, managers should create an initial competency checklist, and build on that to create a training program that includes: Daily assigned readings Regular mentoring and job shadowing Daily assigned homework Those daily readings should include: AHIMA and ACDIS physician query practice briefs AHIMA and ACDIS Code of Ethics Official Guidelines for Coding and Reporting»»» Key references from the AHA s Coding Clinic for ICD-9-CM» Frequently used terminology such as CC/MCC, MS-DRG, relative weight, Recovery Auditors, compliance, etc. Job shadowing regimens should include one-on-one time with the manager for at least the first week and should incorporate shadowing other CDI staff members in their daily practices, similar to what Foster and Seekircher put into place. The shadowing process should be three-fold, says Prescott: 1. Listen: The new employee should round with his or her coworkers, listening to their interactions with physicians and other staff members and watching what they do. 2. Mirror: The new staff member and coworker should review the record together, with the new employee offering suggestions while the mentor points out additional review possibilities. Sample goals Clear goals provide training framework The following goals were developed by Kerry Seekircher, RN, CCDS, documentation improvement specialist supervisor at Northern Westchester Hospital in Mount Kisco, N.Y., to help her facilitate the training of two new CDI specialists who were hired in The goals allow the new staff to visualize where they should be in their education at various points along the continuum. Objective The Clinical Documentation Specialist will be responsible for facilitating concurrent and retrospective queries for documentation necessary to capture all significant diagnoses in the inpatient medical record. The Clinical Documentation Specialist assists in improving the accuracy of our facility s publicly reported data as well as improving financial reimbursement by capture of the most appropriate DRG assignment. Three-month expectations Upon completion of an extensive three-month fellowship program, the Clinical Documentation Specialist will be able to: Independently perform chart reviews on selected patient care unit(s) (with the understanding that ongoing support is always available and expected to be utilized) Select the most appropriate principal diagnosis as per the current documentation and identify the need for a query to further support a higher-acuity diagnosis Identify comorbid and major comorbid conditions as per the current documentation and identify the need for a query to further support higher-acuity diagnoses Effectively deliver queries in a compliant, non-leading manner Maintain organization as evidenced by follow-up reviews, timely responses to queries, and a final review to ensure capture of all appropriate information in the CDIS database 12 January HCPro, a division of BLR.

13 3. Review: The new staff member conducts record reviews on his or her own while being shadowed by a manager or experienced coworker. The first step is a learning, educational piece, says Prescott. The second is a hands-on, next step process, and the final piece is a testing of their learned skills and a reinforcement of their accrued abilities. Shadowing should also include time beside the inpatient coding team, Prescott says. Ask the inpatient coders to talk through their process as they are coding the records. The results can be enlightening for both sides of the experience. Shadowing can also be expanded to other areas, such as case management and quality, so the new staff members gain an understanding of how the CDI role affects various departments. Additionally, Prescott recommends new hires line up a series of meetings with various department heads to discuss how clinical documentation affects their work. The CDI manager can either set up the meetings or ask the new staff member to arrange them. By taking meeting organization into his or her own hands, the new staff member gets a chance to become comfortable with other professionals, learns the role s need for interactivity, and has an opportunity to practice his or her interpersonal and investigative skills. This isn t a meeting where the two individuals talk about the weather, but where the CDI specialist is expected to ask pointed questions about the role of the person sitting across from them and how CDI efforts can help, says Prescott. Such meetings may take place once or twice a week; they can include the HIM director, the nurse managers, the physician advisor, and even ancillary employees such as dietitians or IT staff members. I am a big fan of the idea that you can t do it alone, says Prescott. So when people hire new staff, there really needs to be that supportive environment built under them to ensure their success. There is always something more to learn, especially in this profession. That s just one of the things that makes it so rewarding. Implement basic concepts of who, when, and when not to query as per the AHIMA practice brief Managing an Effective Query Process (2001) Six-month expectations As above Achieve improved accuracy in DRG selection Increase number of chart reviews, as discussed with supervisor, as well as achieve an increased number of appropriate and compliant queries Participate in the formulation of physician/nurse practitioner education tools (providing input to CDS newsletter/tip of the week and assisting with presentations) Participate in ongoing CDS training and preparation for ICD-10 One-year expectations As above Assist in implementation of ICD-10 Certification is strongly encouraged following two years of employment in order to: Foster professional growth and ongoing commitment to excellence as a Clinical Documentation Specialist Increase the number of nurses with certification as per the current recommendation by the American Nurses Credentialing Center for Magnet hospitals (CCDS is one of the recognized certifications by Magnet) Two-year expectations As above Serve as a mentor and role model for new hires Serve as an educator and resource to both the coding and clinical staff Obtain CCDS certification Independently conduct ongoing education sessions for clinical staff Identify problem area(s) requiring additional attention and focus and strategize in order to make necessary improvements 2014 HCPro, a division of BLR. January

14 EHR: Three implementation stories from the CDI front lines First came the computerized physician order entry (CPOE) system. Next staff implemented an electronic query/cdi system. Finally there was a move to a full electronic health record (EHR). When Emory University Orthopedic & Spine Hospital in Tucker, Ga., decided to phase out various elements of its traditional, paper medical record charts, it took things one piece at a time, says Linda Franklin-Yildirim, RN, CCDS, a CDI specialist at the facility. Unfortunately, integration of the various systems was far from seamless. For example, after composing a query, Franklin-Yildirim and her CDI teammates would have to leave a query notification in the EHR system s inbox for the physician, and then send the physician a pager message letting them know a query was waiting for them. That s how long ago we re talking, she says with a laugh. We were on pagers! The physician would get our message, and they would go open their inbox and document their response in the medical record if applicable. At the time, the physician query response rate was as low as 63%, Franklin-Yildirim says. To combat this problem, the team held in-services to explain how to access the queries and maneuver within the EHR. Their response rates began to steadily improve today it s roughly 98%. The initial struggle for Emory s CDI staff was getting the query into a user-friendly format for the physicians. They want to make their records as complete as possible, but it has to be simple for them, says Franklin-Yildirim. CDI specialists really need to be the ones to help on this. We need to make those highlighted points as to how to use the system and why it s necessary, to make it as easy and convenient as possible for them. Today, Emory s physicians understand how to navigate the EHR and can access their queries from their inbox at their convenience. Some physicians opt to respond after they get out of surgery, while others send Franklin-Yildirim their answers late in the evening. For them, it s about finding what suits their workflow and lifestyle, she says. If it s convenient for them, I ll get query responses sometimes at seven or eight at night. The key to successful implementation, Franklin-Yildirim says, is the same no matter the project: Enlist individuals who have energy and passion for the project to participate in the rollout, educate peers, and work with the team to seek methods of process improvement. Once they see how successful it can be, everyone wants to get on board, she says. Simplifying the process When Bernadine Darienzzo, RN, CCDS, CDI supervisor at Boston Medical Center (BMC), started at the 496-bed academic facility three years ago, the team had to carry their laptops to the hospital floors due to a lack of available floor computers and work space. This arrangement led to communication problems. Laptop batteries would run out in a matter of hours, and it proved difficult to review charts and engage in conversations with the physicians during patient rounds. We tried to tag along, but rounds are fast paced and focused on daily orders and discharge planning. Physicians had mostly just come from seeing their patients, so they were not going directly back to the charts. It just wasn t the place or time for us, she says. It just wasn t efficient or productive. BMC is a private, not-for-profit facility and one of the busiest trauma centers in New England, says Darienzzo. The physicians supported the new program, but they felt it was disrupting patient care. As BMC became one of Boston s first facilities to integrate an EHR, the CDI process migrated away from a floorbased approach. CDI specialists took to their own offices and attached queries to s. Physicians had 24 hours to respond, and the team would send a reminder text message to their pagers. If a physician did not respond, he or she would receive another pager message and a follow-up . This was just such an involved process, Darienzzo says, and we wanted to improve our productivity as well as our physician response rates. After BMC migrated to a fully electronic query system, Darienzzo and her team didn t rely on the new program to solve their query problems. She worked with BMC s IT team and the vendor to ensure physicians received queries in an effective yet unobtrusive manner. The IT team made sure that whenever physicians entered the EHR to update their progress notes, they first saw the queries attached to the note. They 14 January HCPro, a division of BLR.

15 would read the content of the query, then scroll down to write their note. According to Darienzzo, the positive outcomes of this new process were immediately apparent. They included: A 70% decrease in follow-up queries A 98% physician query response rate Giving physicians the ability to respond to queries when and where they document their progress note (e.g., in the office, at home, or on the floor) rather than having to remember a query and find it in an alternative system Now BMC is embarking on an even bigger EHR shift transitioning multiple electronic software systems to one comprehensive vendor over a two-year period. Two physicians on the planning committee were adamant that they did not want to lose the convenience of the current query interface, so Darienzzo and her team have a seat at the transition planning table. Thankfully, she says, the team is analyzing the workflow to see how CDI specialists interface with the electronic systems and how that information flows to physicians and coders. They really want to match interface to interface, Darienzzo says. Those seeking to emulate BMC s EHR success story may opt to follow Darienzzo s two-part advice. First, she says, find a supportive IT partner who will listen to your needs and help you brainstorm solutions. Second, remember your own mission and keep physicians engaged by focusing on the mission and not the almighty dollar. Connecting systems at the start The 300-plus bed Sibley Memorial Hospital, a member of John Hopkins in Washington, D.C., specializes in obstetrics, oncology, and orthopedics. Like many facilities, Sibley struggled at the outset of EHR implementation to bring the various facets of multiple systems together into one unit. The ED has one system, the radiology department has another, laboratory department uses something else, and billing and finance have yet another, says Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, MCP, who now works as the director of auditing and CDI services for Trust HCS in Washington, D.C. At Sibley, Dominesey explained how CDI fit into the EHR implementation process and worked to gain allies within the IT, HIM, and finance departments to prove that CDI specialists needed to be involved. He also strove to identify opportunities for collaboration with IT staff to develop simple and effective in-house solutions where vendor products proved too costly and/or cumbersome for the overall system. CDI specialists need to serve as subject matter experts to advocate for systemwide standards for certain controversial clinical conditions, such as acute respiratory failure, sepsis, and acute kidney disease much as they would when developing systemwide query forms, Dominesey says. Additionally, CDI staff can help IT integrate likely clinical scenarios based on indications, medications, and other documented conditions. Finally, they can help integrate necessary ICD-10-CM/PCS elements and craft easy-to-use query templates. Since physicians have become used to CDI specialists as their go-to documentation team, most of them feel comfortable working through the EHR processes with the specialists. CDI staff can provide physicians and other clinical staff with information regarding EHR use and resource management; they can also help clinicians see how their documentation gets reflected in quality ranking scores. Having a designated CDI person as an EHR documentation resource person is a great idea, but that responsibility should be written into a new staff member s job description so that aspect doesn t overwhelm their typical chart review priorities, notes Dominesey. Although some may be clinging to the paper chart, the pre-ehr world just isn t viable anymore. However, if physicians are forced to point and click their way through the EHR, then we will lose any of the benefit associated with the transition, Dominesey says. CDI principles have to be included during the outset of the process, and ongoing assessment of those tools needs to be developed into an additional CDI target area. CDI principles need to be baked into the electronic solution and not be sandwiched in later as an afterthought. Editor s note Franklin-Yildirim is a former leader of the Georgia ACDIS chapter. She related her experiences with electronic query implementation to the group during its fall 2013 meeting. Darienzzo presented a poster on this topic at the 2013 ACDIS national conference in Nashville. Dominesey was a speaker at the 2013 ACDIS conference. ACDIS members can download his PowerPoint presentation from the Forms & Tools Library at HCPro, a division of BLR. January

16 Meet a member What a trip: Member recounts CCDS exam experience Christina Raad, RN, CCDS, works at Central DuPage Hospital in Winfield, Ill., and has been a member of the Northern Illinois ACDIS networking group and a CDI specialist for 10 years. She has three wonderful children, two lovely daughters-in-law, and three grandkids, with a fourth on the way. Raad recently wrote to ACDIS to say that, surprisingly, she enjoyed taking the Certified Clinical Documentation Improvement Specialist (CCDS) exam! So many people write to express their worry or to say how daunting the exam seems, but Raad has quite a different story. CDI Journal: How did you come to enjoy taking the CCDS exam? Raad: The night before the exam I was walking my dog, Charlie, and I fell. I tripped over a bump on the sidewalk, skidded on the cement, and knocked out a front tooth. I was bleeding everywhere from numerous abrasions (mostly on my face) and my glasses were badly scratched. Thankfully, I wasn t too badly injured. So I got up quickly, and was glad to see Charlie right there waiting for me. I did not want someone to see me and call 911! I got myself home and was glad to see I did not need stitches. I applied ice and went to bed because I knew I was taking my test the next morning. The next morning, I looked pretty sad. It wasn t just a bad hair day; it was a bad face day! My top lip was massively swollen. I sort of looked like a duck. So to pass the test after not sleeping very well and looking like I did, well, it meant that my brain works pretty well and that I really do know my stuff when it comes to my role in CDI. I was looking forward to taking the test all week. I m 65 and may be getting older, but my mind and spirit are just fine. This year I received my Medicare card (a mandatory process when you turn 65). It startled me to see the red, white, and blue card which I previously associated with old people there in my hands with my name on it. At any rate, I knew halfway through the test that I would pass and that I m competent at CDI. I m very grateful to ACDIS for the information on their website that I used to study for the exam. CDI Journal: Not only did she pass, she scored an 87! Will you tell us what prompted you to decide to sit for the credential? Raad: I am not sure why I did not get the CCDS certification years ago, but I decided that if I could qualify for Medicare, I should certainly get certified. I studied by using my DRG book instead of the grouper for a month, and went through many of the ACDIS blogs and old conference material. I was really excited to take the test. CDI Journal: What did you do before becoming a CDI specialist? Raad: After graduating from a three-year diploma program (does anyone else remember what a hopper is?) I worked in the ED. I also have worked in a psychiatric hospital, home health, staff development, in an allergy and asthma clinic, case management, and in a nursing home. Courtesy Photo Christina Raad poses with her pet Charlie. CDI Journal: Why did you decide to make the career switch to CDI? Raad: I took a job as a case manager and was not very happy, so when a coding position was created, I applied. The job description was rather vague, but I really wanted to make a move. It s one of the best impulsive decisions I ever made. 16 January HCPro, a division of BLR.

17 CDI Journal: What has been your biggest challenge? Raad: Developing the ability to see a medical record as a coder interprets it, trying to discern what the physician thinks he is documenting, then using my clinical knowledge to connect it all together was a difficult thing to learn. The interpersonal skills required were also difficult to manage. You have to balance egos, feelings, personalities, compliance issues, administrative goals, and still come out smelling like a rose. And that s not easy! CDI Journal: How has the field changed since you began working in CDI? Raad: It has changed tremendously from a financially based program, fairly limited in scope, to one that emphasizes quality documentation in many different areas. A CDI program today can be very different from one institution to another. I love the creativity I see among various programs. CDI Journal: Can you mention a few of the gold nuggets of information you ve received from colleagues on CDI Talk or through ACDIS? Raad: I had been doing CDI for several years, but other than my coworkers, I had met just a couple of other CDI specialists. When ACDIS started up, I felt like I had found a support group for my non-dysfunctional problem! Finally there were people who could commiserate with my experiences, encourage me to keep at it people who simply just understood what it means to be a CDI. Besides that, I am grateful to ACDIS for all the fine education, resources, and networking opportunities they have provided. And I am grateful to the CDI nurses and the coders I work with for all they have taught me. Onward to the next challenge: ICD-10! CDI Journal: If you could have any other job, what would it be? Raad: A studio musician in a recording studio. CDI Journal: Can you tell us about a few of your favorite things? Vacation spots: Anywhere Hobby: Sewing, quilting, knitting, crocheting Non-alcoholic beverage: Diet Dr. Pepper Foods: Mexican Activity: Yoga/Pilates/meditation Editor s note CDI Journal introduces an ACDIS member in each issue. If you would like to be featured or know someone who would, please ACDIS Member Services Specialist Penny Richards at prichards@cdiassociation.com. Fight the Recovery Raiders! Conduct reviews with Recovery Auditor denials in mind by Trey La Charité, MD Reducing mistakes and eliminating fraud are the dual goals in today s claims auditing environment. While these goals are admirable, the aggressive strategy typically executed by Recovery Auditors and other auditing agencies to achieve those goals is fundamentally flawed. The reality is that our healthcare facilities are subjected to a myriad of Recovery Raiders that scrutinize everything from how many units of a drug were billed to whether or not a patient actually needed to be admitted to the hospital. Whether contracted by the federal or state government or employed by the private insurance companies, these entities lack appropriate oversight and accountability. Coding is hard, our coding system is complex, and yes, we humans make coding mistakes. However, honest coding errors do not warrant the brazen tactics employed by auditors in an effort to grow their coffers at the expense of our patients care. The unfortunate reality is that most facilities do not have the resources necessary to lobby Washington to correct the current situation. Being pragmatists, we must do the best we can with the resources we have HCPro, a division of BLR. January