By Beth Friedman, RHIT, BSHA
The Ninth Annual Association for Clinical Documentation Improvement Specialists (ACDIS) Conference was held May 23 through 26 at Atlanta’s World Congress Center. With nearly 2,000 attendees and more than 70 exhibitors, the conference was the largest gathering of clinical documentation improvement (CDI) specialists to date. Key topics included sepsis, value-based purchasing, remote CDI services, and ethical best practices for CDI programs.
Sepsis Documentation Takes Center Stage
Two standing-room-only panel sessions focused on the newly released definitions of sepsis and septic shock (Sepsis-3). James Fee, MD, CCS, CCDS, vice president of Enjoin, moderated a special physician panel to review The Journal of the American Medical Association’s revised definitions and diagnostic criteria. Attendees also debated early adoption vs participation in the Surviving Sepsis Campaign and ICD-10 reporting. Sepsis documentation and coding continue to be an important topic across all health care stakeholders, with Fee encouraging attendees to coordinate and collaborate across their organizations.
CDI Specialists’ Role in Value-Based Purchasing
Sabrina Yousfi, MBA, RHIA, CCS, an AHIMA-approved ICD-10 trainer and vice president of coding at CIOX Health, reflected on the importance of preparing for value-based purchasing. Following the opening keynote session by Richard E. Wild, MD, JD, MBA, FACEP, chief medical officer at the Atlanta Regional Office of the Centers for Medicare & Medicaid Services, Yousfi emphasized how Wild “set the stage for CDI’s steady shift from revenue-focused to outcomes-driven by clarifying how physicians and hospitals that can demonstrate low cost and high quality will reap the rewards of value-based purchasing.”
CDI Programs Go Remote
Remote CDI was another hot topic at ACDIS. There was an educational session led by SCL Healthcare and a private focus group sponsored by TrustHCS. Jana Armstrong, RHIA, CPC, executive director of consulting for TrustHCS, reiterated the difference between remote CDI specialist staffing and full-service CDI coverage. “Most established CDI programs want to expand into outpatient areas and all payer types, but they simply can’t find or keep enough qualified CDI specialists to maintain the additional workload,” Armstrong remarked. A hybrid combination of remote CDI specialist staff with strong onsite liaisons and physician advisors may be the industry’s ideal solution in the years ahead.
Amy Czahor, RHIT, CDIP, CCS, vice president of optimization and analytics services for RecordsOne, added that a full EHR coupled with CDI software and strong analytics is foundational for a remote CDI program. Czahor also stated, “Hospitals and health systems should only attempt remote CDI after their in-house programs are firmly established.”
CDI Ethics Refreshed
Members of the ACDIS Advisory Board led a jam-packed panel session to overview 11 ethical principles and associated case scenarios included in the association’s October 2015 release of an updated Code of Ethics. According to advisory board member Wendy Clesi, RN, CCDS, CDIP, director of CDI services for Enjoin, the scenarios discussed during the session represent “real-world challenges and ethical dilemmas cited by our members and faced by CDI specialists every day.” Attendees walked away with solid advice and a clear mandate: Establish policies to handle difficult CDI situations before they occur, review them frequently, and update them when new ethical issues arise.
Remembering Dr. Robert S. Gold
This year’s conference also marked the passing of Robert S. Gold, MD. For nearly 20 years, Gold was an active member of the ACDIS community. He is fondly remembered for sharing his knowledge, vision, and enthusiasm for clinical documentation, coding, and quality patient care. We will all miss Gold’s passion and presence in our industry. Rest well, our friend.
— Beth Friedman, RHIT, BSHA, is founder and chief content officer of Agency Ten22.