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July 7, 2008

Organization Serves CDI Specialists’ Needs
By Brian Murphy, CPC
For The Record
Vol. 20 No. 15 P. 6

On October 1, 2007, clinical documentation improvement (CDI) specialists finally found a place to call their own when the Association of Clinical Documentation Improvement Specialists (ACDIS), a community developed by and for CDI specialists, was launched. Since then, many CDI specialists have found a home with the association.

“Being a member of ACDIS has given me the opportunity to network with other professionals performing the same role,” says ACDIS member Colleen Stukenber, RN, MSN. “Being that we are a small but growing group nationwide, it is important to have an association to share information.”

Call it good timing or plain old karma, but October 1 also coincided with the debut of Medicare severity diagnosis-related groups (MS-DRGs). This new coding and reimbursement system brought sweeping and profound changes to the DRG system, which had been relatively stable since its 1983 inception. MS-DRGs require physicians to document to exacting degrees of specificity and capture all the patients’ diagnoses in the medical record, including whether they were present on the patients’ admission to the hospital. Their documentation—and the codes ultimately reported in the HIM department—are what drive the hospital’s reimbursement. CDI specialists are challenged to meet these demands every day.

But CDI specialists face more challenges than just changing Centers for Medicare & Medicaid Services (CMS) regulations and updated coding guidelines. Hospital data are in the process of becoming fully transparent and available to the public, allowing patients to make informed choices about which hospitals to seek out for care. All these factors require physicians to record accurate, detailed, and complete medical records—and that is where the CDI specialist and the ACDIS step in.

“Worldwide, acute care hospitals are subject to a variety of quality and information reporting mandates whereby the reported information is derived solely from physician documentation in patients’ medical records,” says Lynne Spryszak, RN, a member of the ACDIS advisory board. “ACDIS’ goal is to improve and support CDI specialists’ efforts to ensure that the information reported to agencies such as CMS is specific and is an accurate reflection of the institution’s severity of illness, risk of mortality, and quality efforts.”

Job Responsibilities
CDI specialists’ role includes reviewing inpatient medical record documentation concurrent to a patient’s stay. They analyze a patient’s clinical status and review the record for accuracy and specificity of diagnostic terminology. When the documentation is lacking or vague, they are required to query physicians for further information. Many liken the job to that of a detective because hunting down clues, asking questions, and tying up loose ends in the chart are the position’s bread and butter.

CDI specialists also work closely with coding staff to ensure that the documentation of discharge diagnoses and coexisting comorbidities are a complete reflection of a patient’s clinical status and care, adds Cindy Basham, MHA, MSCCS, BSN, CPC, CCS, a member of the ACDIS advisory panel. “They apply basic knowledge of the American Health Information Management Association [AHIMA] standards of coding for evaluation of medical record documentation. And they ensure timely, accurate, and complete documentation of clinical information, which is used for measuring and reporting physician and hospital outcomes.”

Many CDI specialists carry the additional responsibility of providing nurses, physicians, and other clinical staff with educational sessions about documentation improvement, identifying strategies for sustained work process changes that facilitate complete and accurate clinical documentation, and assisting in quality measures collection. This combination of clinical and coding knowledge, an ability to teach complex topics in tight time frames, and a willingness to engage busy physicians in open dialogue requires an individual with unique traits and specialized training.

While their backgrounds vary—CDI specialists are often former nurses, case managers, coders, or quality professionals—they’re alike in that they must form a dynamic and positive working relationship with their HIM/coding departments to succeed. Establishing a team-first, all-in-this-together approach is a must, says ACDIS advisory panel member Gloryanne Bryant, BS, RHIA, RHIT, CCS.

“Having an association that directly addresses CDI in a collaborative manner between the HIM/coding professionals and nursing professionals is a much-needed consortium,” she says. “Due to the complexity of our healthcare system, the association provides a venue to share best practices in this area and learn from one another, which is a key to the bond of the association members and what makes it unique and beneficial.”

ACDIS as a Resource
To meet the varied and specialized needs of its diverse membership, the ACDIS assembled a panel of 12 professionals, including physicians, former nurses and case managers, coding professionals, and HIM directors, to serve as resources and guides. The advisory panel members are Basham; Bryant; Jean S. Clark, RHIA; Wendy De Vreugd, RN, BSN, PHN, FNP; Colleen Garry, RN, BS; Robert S. Gold, MD; William E. Haik, MD; Tamara Hicks, RN, BSN, CCS; Pam Lovell, MBA, RN; Shannon McCall, RHIA, CCS, CPC; Spryszak; and Heather Taillon, RHIA.

The ACDIS currently consists of slightly more than 1,000 members representing all 50 states. For Taillon, providing a single place to network and share ideas with peers has been the biggest benefit.

“Personally, I have learned so much from the other members of the board. It is a great resource for me when I am struggling with how to clarify a confusing issue or come up with the best answer for a difficult situation,” she says. “I think it is also impressive that a group as diverse as ours can sit down together and collaborate and share ideas on best practices. As a result of ACDIS, I feel we have begun to lay the groundwork for guidance on day-to-day processes for clinical documentation programs across the country.”

Prior to the launch of the ACDIS, CDI specialists did not have a dedicated resource that allowed them to network, share ideas, read about trends and new regulations in the field, and learn about effective best practices. The ACDIS fills that need by offering a quarterly newsletter, an active talk group, a forms and tools library, quarterly conference calls, e-learning courses, a CDI blog, and more.

“I appreciate the ACDIS association for many reasons, but the primary one that immediately came to mind was support and networking,” says Christina Raad, RN. “I have been doing this program for over five years, wondering if anyone else out there struggled with finding information on asking queries, physician education, how to capture data, etc. It has been most rewarding and beneficial for me to find a community of colleagues who will share their ideas, brainstorm, and validate my role.”

The ACDIS held its first annual conference in May in Las Vegas. At the conference, 380 members attended sessions about disease processes, achieving physician buy-in, CDI program implementation, and formulating compliant and effective physician queries, a red-hot topic in the healthcare field. In fact, the AHIMA is currently revamping its physician query practice brief. Through the ACDIS, many CDI professionals have voiced their opinions to the AHIMA about what constitutes a nonleading query and how CDI professionals deserve recognition for taking the lead in the query process.

“Attending the conference in Las Vegas strengthened the association as it brought many of us together,” Stukenber says. “One of the biggest challenges the group is presently facing is the direction of how to appropriately query physicians. As a CDI professional, I believe we should have a say in how we ask physicians questions concerning patients’ conditions and accurate documentation.”

The Future
The ACDIS has big plans in store for the remainder of this year, as well as the next. Foremost is the creation of a CDI credential. To this end, the ACDIS has assembled a 12-member panel from its membership base to draft a rigorous, comprehensive examination to achieve certification. The goal is to create an independent credential that CDI specialists can proudly possess, one that will elevate their professional standing and allow them to achieve a mark of distinction among their peers.

Other plans include a dedicated job search Web page and local and regional chapters. The ACDIS also announced that it will hold its second annual conference next May, again in Las Vegas. At every step of the way, the ACDIS will be asking its members to be actively involved in all its decisions.

For more information, please visit www.cdiassociation.com.
— Brian Murphy, CPC, is director of the Association of Clinical Documentation Improvement Specialists.