cdijournal · director, consulting services 3m health information services atlanta, ga...

continued on p. 2

January 2010 Vol. 4 No. 1

FEATURESDirector’s note 6n We’ve asked the advisory

board what makes a good CDI specialist.

CCDS celebration 7n See who recently passed

the Certified Clinical Documentation Specialist credentialing exam.

Clinical corner 8 n Jon W. Arnott, MD,

CMQ, explains how documenting the dying process can improve predicted mortality rates.

MCC 10n Use these tips to obtain

MCC clinical documentation specificity.

Local chapter map 12n With more than two dozen

local meetings to choose from, CDI specialists can take their pick of networking opportunities.

CDI staffing segment 16n Learn why now is the

time to implement CDI programs.

cdiJournalRAC review

Complex DRG audits reveal CDI target areas

Connolly Healthcare, CMS’ recovery audit contractor (RAC) for Region C, announced its first targets for complex review in December 2009. Connolly’s list of 24 DRGs is the first published, so it provides a good preview of what other RACs may target. The reviews were expected to begin in January.

The release of the targeted MS-DRGs “is and isn’t big news,” says Lynne A. Spryszak, RN, CCDS, CPC-A, manager at Precyse Solu-tions, LLC, in Wayne, PA. The Program for Evaluating Payment Patterns Electronic Report, the Office of Inspector General’s annual Work Plan, and even Ingenix’s DRG Expert offer clues to suspect DRGs of which CDI specialists should be wary.

“CDI specialists should be aware of some of these items since it’s not the first time they’ve been targeted,” Spryszak says. “But the release of Connolly’s list should add motivation to existing CDI programs’ concurrent review practices.”

Double-check surgical documentationThe bulk of the items stem from surgical

DRGs, which may not come as a surprise to experienced CDI specialists, says Spryszak.

“I can certainly see why most of the DRGs Connolly is targeting are surgical DRGs,” says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Marblehead, MA.

A patient may undergo a procedure for a variety of reasons, so providers would group an

admission to a particular DRG based on the combination of the principal diagnosis, any pres-ent accompanying additional diagnoses (i.e., CCs or MCCs), and the principal procedure, McCall explains. Therefore, if the provider reports an incor-rect code as the principal diagnosis, the assigned DRG may not be correct.

Similarly, principal procedures are by defini-tion definitive in nature (as opposed to diagnos-tic or exploratory procedures), McCall says. So if two procedures meet the criteria, the provider should select the one most closely related to the principal diagnosis, per the October 1990 AHA Coding Clinic.

For all the items listed on Connolly’s release, facilities need to implement a second line of preemptive defense, says Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS, director at Precyse

2 January 2010 © 2010 HCPro, Inc.

For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, please contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.

Editorial Board Cindy Basham, MHA, BSN, CPC, CCSCEO/Key Consulting, Inc.Senior Quality Documentation Improvement Consultant VHAMaryville, [email protected]

Gloryanne Bryant, RHIA, CCS, CCDSRevenue Cycle Kaiser Permanente Oakland, [email protected]

Shelia Bullock, RN, MBA, CCM, CCDS Manager, Clinical Documentation ServicesUniversity of Mississippi Medical CenterJackson, [email protected]

Jean S. Clark, RHIAService Line Director for HIMRoper St. Francis HospitalCharleston, [email protected]

Wendy De Vreugd, RN, FNPSenior Director of Case ManagementKindred Healthcare, Hospital DivisionOrange County, [email protected]

Garri Garrison, RN, CPUR, CPC, CMCDirector, Consulting Services3M Health Information Services Atlanta, [email protected]

Colleen Garry, RN, BSClinical Documentation ManagerNYU Medical CenterNew York, [email protected]

Robert S. Gold, MDCEODCBA, Inc.Atlanta, [email protected]

William E. Haik, MD, FCCPDirectorDRG Review, Inc.Fort Walton Beach, [email protected]@aol.com

Tamara Hicks, RN, CCS, CCDSManager, Care CoordinationNorth Carolina Baptist HospitalWinston-Salem, [email protected]

Robin R. Holmes, RN, MSNManager, Clinical Documentation ImprovementDCH Health SystemTuscaloosa, [email protected]

Pam Lovell, MBA, RNRegional Director, Clinical Intake TeamHumana, Inc.Louisville, [email protected]

Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I Director of HIM/Coding HCPro, Inc. Marblehead, MA [email protected]

Lynne Spryszak, RN, CPC-A, CCDS Senior ConsultantFTI HealthcareBrentwood, [email protected]

Colleen Stukenberg, MSN, RN, CMSRN Clinical Documentation Management ProfessionalFHN Memorial [email protected]

Heather Taillon, RHIA Manager of Coding Compliance St. Francis Hospital Beech Grove, [email protected]

CDI Journal (ISSN: 1098-0571) is published quarterly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: $129/year for membership to the Association of Clinical Documentation Improvement Specialists. • Postmaster: Send address changes to CDI Journal, P.O. Box 1168, Marblehead, MA 01945. • Copyright © 2010 HCPro, Inc. 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, Inc., or the Copyright Clearance Center at 978/750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. For renewal or subscription informa-tion, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: [email protected]. • Visit our Web site at www.cdiassociation.com. • 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.

ACDIS Director: Brian Murphy, CPC [email protected]

Associate Director: Melissa Varnavas, [email protected]

Publisher: Lauren McLeod

Solutions. “Make sure the bill is not dropped on these DRGs until the CDI team or other specialist conducts a second review of the medical record,” Brown says.

This concept is also pertinent for the issues involving proce-dures unrelated to the principal diagnosis DRGs, McCall notes. These DRGs have high relative weights and should be reported infrequently.

“They have long been a target for payers because of their high weights as well as the unlikelihood of their occurrence, especially these days with admission criteria and procedures being done more commonly in the outpatient setting,” says McCall.

For example, consider the following 2010 weights for Connolly targets: » MS-DRG 981, extensive OR procedure unrelated to principal diagnosis with MCC: weight 5.0389 » MS-DRG 982, extensive OR procedure unrelated to principal diagnosis with CC: weight 2.8954 » MS-DRG 983, extensive OR procedure unrelated to principal diagnosis without CC/MCC: weight 1.8072 » MS-DRG 987, nonextensive OR procedure unrelated to principal diagnosis with MCC: weight 3.4020

» MS-DRG 988, nonextensive OR procedure unrelated to principal diagnosis with CC: weight 1.7836 » MS-DRG 989, nonextensive OR procedure unrelated to principal diagnosis without CC/MCC: weight 1.0358 » Septicemia and ventilation DRGs

Maintain sepsis focusThe septicemia diagnosis has been problematic for some

time, McCall says. Coders often misunderstand the ICD-9-CM Official Guidelines for Coding and Reporting as it pertains to the sequencing of the assigned codes, she says.

“This is especially true with sepsis as it relates to septi-cemia and other underlying infections that can cause sepsis,” McCall says. Many think the guidelines require septicemia to always be the principal diagnosis, when in fact that may not be the case depending on the documentation.

The Official Guidelines state the following: “Sepsis/SIRS with Localized Infection: If the reason for

admission is both sepsis, severe sepsis, or SIRS and a localized infec-tion, such as pneumonia or cellulitis, a code for the systemic infection (038.xx, 112.5, etc) should be assigned first, then code 995.91 or 995.92, followed by the code for the localized infection. If the patient is admitted with a localized infection, such as pneumonia, and sepsis/SIRS doesn’t develop until after admission, see guideline I.C.1.b.2.b. (b) Sepsis and severe sepsis as secondary diagnoses: When sepsis or

RAC reviewcontinued from p. 1

© 2010 HCPro, Inc. January 2010 3


severe sepsis develops during the encounter (it was not present on admission), the systemic infection code and code 995.91 or 995.92 should be assigned as secondary diagnoses.

So, McCall says, it would “depend on the circumstances surrounding the admission” because if the patient did not devel-op sepsis until after admission (i.e., not present on admission) the systemic infection code (e.g., 038.9) and sepsis (995.91 or 995.92) would be used as secondary diagnoses.

“Sepsis and septicemia rules can be so difficult to apply. In fact, citation of the one coding guideline is primarily the reason why RACs are focusing on these MS-DRGs since it seems to imply that whenever a patient has sepsis and a localized infec-tion, no matter when it occurred during an admission, that the principal diagnosis is automatically a code from the 038.xx series which will group to MS-DRGs 870–872,” says McCall. continued on p. 4

Connolly lists 24 DRGs for review

The recovery audit contractor for Region C, Connolly

Healthcare, announced MS-DRG target areas for complex

review in December 2009. According to its Web site, the

24 approved MS-DRG validation issues are:

» MS-DRG 163: major chest procedures with MCC

» MS-DRG 164: major chest procedures with CC

» MS-DRG 165: major chest procedures without CC/MCC

» MS-DRG 166: other respiratory system OR procedures

with MCC


with CC


without CC/MCC

» MS-DRG 207: respiratory system diagnosis with ventilator

support 96+ hours

» MS-DRG 255: upper limb and toe amputation for circulatory

system disorders with MCC

» MS-DRG 329: major small and large bowel procedures

with MCC

» MS-DRG 330: major small and large bowel procedures with CC

» MS-DRG 331: major small and large bowel procedures with-

out CC/MCC

» MS-DRG 372: major gastrointestinal disorders and peritoneal

infections without CC/MCC

» MS-DRG 386: inflammatory bowel disease with CC

» MS-DRG 394: other digestive system diagnoses with CC

» MS-DRG 432: cirrhosis and alcoholic hepatitis with MCC

» MS-DRG 813: coagulation disorders

» MS-DRG 871: septicemia without mechanical ventilation 96+

hours with MCC

» MS-DRG 872: septicemia without mechanical ventilation 96+

hours without MCC

» MS-DRG 981: extensive OR procedure unrelated to principal

diagnosis with MCC


diagnosis with CC


diagnosis without CC/MCC

» MS-DRG 987: nonextensive OR procedure unrelated to principal

diagnosis with MCC


diagnosis with CC


diagnosis without CC/MCC

For example, in an admission in which the patient has sepsis due to an underlying infection (e.g., pneumonia), the sequencing could change depending on the physician’s docu-mentation. The instructional note for code 995.91 (sepsis) states that coders should sequence the underlying infection first, which could be pneumonia (code 486) or septicemia (code 038.xx), depending on the circumstances surrounding the admission.

CDI specialists should also keep a watchful eye on com-mon-sense mistakes that pertain to RAC-targeted DRGs, particularly as they relate to a patient’s length of stay, says Brown.

“The higher weighted DRG may fall out against a short-er length of stay,” Brown says. For example, if a patient has



the principal diagnosis of septicemia with a MCC but the patient was discharged home after one or two days, it could raise a red flag to pull that case for further review.

“Something’s potentially wrong there with a higher-severity case and a short length of stay. If I am a RAC, I would pull that chart for review, run a report, and check similar cases to look for trends and/or patterns. CDI spe-cialists need to be on the lookout for common-sense items like these,” Brown says.

“Ventilation is also tricky,” says McCall. “This is another area that has specific guidelines on when it can be reported, and coders have to deal with the time-counting aspect as well.”

mental confusion, which could be inaccurately coded as an encephalopathy (348.xx are MCCs) or malnutrition (severe protein calorie is a MCC),” McCall says.

Join the RAC prep teamRAC prep teams actively meet at many facilities across

the country. (See related article regarding a recent RAC pre-paredness survey on p. 5, and download the benchmarking report at www.revenuecycleinstitute.com). But it’s important that CDI professionals insert themselves into the process and maintain awareness of RAC developments, Spryszak says.

“Facilities need to establish RAC teams and keep lines of communication open so everyone understands how lists like this impact their individual efforts,” she says.

For example, CDI program directors should pull MS-DRG lists by frequency and compare their top 30 to the Connolly list, Brown says.

Depending on resource availability, some programs may wish to run DRG frequency reports going back to October 1, 2007, since RACs are allowed to review medical records going back to that date, says Spryszak.

“As the RACs move into more complex reviews, clearly they are not going to examine every one of the more than 700 DRGs,” Spryszak says. “They’ll look for the top 50 DRGs in their regions, with and without CCs and MCCs.”

“I strongly recommend facilities implement asecond line of reviews to look for patterns in their DRGs,” Brown says. “The real point to take away from this list is that all the CCs and MCCs need to be documented consistently.”

Connolly has provided descriptions of each of the new issues, along with references for providers looking to find more information.

Editor’s note: One of the newly listed MS-DRGs (MS-DRG 372: major gastrointestinal disorders and peritoneal infections without CC/MCC) may contain an error as listed on Connolly’s RAC Web site. The description for MS-DRG 372 is actually “major gastrointestinal disorders and peritone-al infections with CC,” whereas the description provided applies to MS-DRG 373. It is unclear at this time which of the two, either the DRG number or description, has actually been approved for review.

To stay on top of the latest RAC-approved issues in your state, visit the Tools section of the Revenue Cycle Institute Web site and download the updated chart at the top of the page.

RAC reviewcontinued from p. 3

“ Inconsistent education leads to inconsistent documentation. If an MCC shows up one time and one time only, that’s going to lead to review.”

—Lynne A. Spryszak, RN, CCDS, CPC-A

Track CCs/MCCsCDI specialists need to ensure consistent physician docu-

mentation in the medical record, not just for RAC-targeted MS-DRGs, but all CC/MCCs, says Spryszak. If you don’t offer regular education for physicians, examine how your CDI program can improve in that area.

“Inconsistent education leads to inconsistent documenta-tion,” Spryszak says. “If an MCC shows up one time and one time only, that’s going to lead to review.”

The symptoms, procedures, and diagnoses written in the medical record all need to “be clearly and consistently docu-mented throughout the chart to validate that DRG,” Brown says. “If there is a CC or MCC, the CDI specialist needs to make sure it does not come from a single solitary entry in the medical record that could be questionable, but is actually clearly documented and clinically supported.”

It also makes sense to target medical DRGs, those with CCs or MCCs such as cirrhosis and alcoholic hepatitis, says McCall, “because a common symptom and associated sign is



It takes a teamProviders included a wide range of staff members on

their RAC teams, the survey shows. Most teams include medical records, coding, compliance, case management, clin-ical documentation improvement, and patient accounting staff members. But other groups are also represented, with legal staff members and outside consultants present. Nearly two-thirds of respondents reported having physicians on their RAC team, and those physicians play a wide-ranging role when it comes to dealing with RACs, according to respondents.

Follow the leaderSurvey responses indicated that RAC coordinators come

from diverse backgrounds, but many reported having a coor-dinator with a background in HIM/coding or compliance. Several of those who responded “other” said they had a coor-dinator with a background in a combination of the two, or other combinations such as case management and coding or nursing and auditing.

Only 8% reported having a coordinator with a patient accounting background. Other backgrounds mentioned under “other” included auditing, quality, revenue cycle, and risk management.

Educate and be educatedSurvey results indicated that healthcare providers are tak-

ing advantage of RAC education available in a multitude of formats. Fifty-eight percent reported listening to CMS Open Door Forum calls, and nearly two-thirds have attended CMS or RAC education and outreach sessions.

Free audio conferences and Webinars are also popular; more than 75% of survey participants reported taking advan-tage of them. Some respondents also said they read printed literature, e-mail newsletters, and Internet information.

Seventy-eight percent of respondents said their facility has provided internal training on RACs, although nearly 25% have not begun training staff members. Outside consultants, vendors, or other entities are used just 4% of the time for education. Those who conducted internal staff education used general and role-based training methods (30% and 42%, respectively).

Facilities reveal preparation benchmarks for RAC auditsEditor’s note: This article is an excerpt from the HCPro Revenue Cycle

Institute RAC Preparedness Benchmarking Report. Visit www.revenuecycleinstitute.com. to download the report.

In 2009, HCPro’s Revenue Cycle Institute conducted an in-depth study on recovery audit contractor (RAC) prepared-ness among healthcare providers. It garnered 717 responses from all four RAC jurisdictions.

Respondents hailed from healthcare providers of vari-ous sizes: 25% came from hospitals with fewer than 100 beds, another 25% came from hospitals with more than 400 beds, and the remaining 50% were spread in between. Approximately 14% of respondents had participated in the RAC demonstration project.

A high number of respondents already had a RAC pre-paredness program in place (71%). This number could be inflated because providers with heightened awareness of the RAC initiative may have been more likely to respond to the survey, says Kimberly Anderwood Hoy, JD, CPC, author of the benchmarking report and director of Medicare and compliance at HCPro, Inc., in Marblehead, MA.

Otherwise, programs appear to still be in the early stages of preparation. Of respondents with a program in place, 85% started in the past year, and more than 50% started in the past six months. Risk assessments are also well under way, with 75% of respondents saying they have looked at potential risks.

Nearly half of respondents already have a RAC coordi-nator in at least a part-time capacity; coding and compliance were the most popular backgrounds for the coordinator position. Not surprisingly, the survey determined that HIM staff members—from both coding and medical records backgrounds—play a large role in RAC preparation. And eight out of nine represented departments chose to have a director-level position seated at the RAC prep table.

Involving director-level staff members helps ensure that other team members have appropriate direction and budget-ary resources. As teams begin to handle requests from RACs, they may develop into more of a work group with greater staff-level involvement to monitor how requests are pro-cessed, Hoy says.



Director’s note

What makes a good CDI specialist? Clinical skills, detective work, and clear communication

I’ve received a few phone calls lately from people interested in the CDI profession. They want to know: Who are CDI special-ists? Are they qualified to become one?

It’s a difficult question to answer. Many hospitals require an RN licensure. Others

use nurses in combination with HIM/coding professionals, and still others use quality professionals or hospitalists to perform this function. There is no one right answer for which professional to use in the role of CDI specialist.

But what is for certain is that not anyone can be an effec-tive CDI specialist. It’s a difficult job that requires a unique combination of personality traits, knowledge and education, and experience.

According to Marion Kruse, MBA, RN, director at FTI Consulting in Brentwood, TN, it’s imperative to be clinically astute. “You really have to understand the nuances of clini-cal patterns,” Kruse says. “In my opinion, it would be a CDI specialist nurse with CCDS, it would be someone with five years’ experience of true bedside nursing, and ideally some-one with medical and surgical bedside experience.”

An HIM/coding professional can do the job, but he or she cannot be content to simply leave queries for obvious diagnoses. Kruse likens the job to that of a prob-ing detective. For example, if you review a record and see that a patient has received a fluid bolus, the CDI special-ist needs to know that this is typically administered for the following:

» Low blood pressure » Low urine output » High heart rate

The specialist also needs to know some possible diagno-ses associated with the above symptoms, which can include: » Shock » Dehydration » Acute kidney injury » Hypovolemia » Anemia » Low plasma protein levels » Medication side effect (e.g.vasovagal response)

“In general, coders (and inexperienced nurses) will struggle with these types of questions,” Kruse says. “However, this is the type of knowledge needed to be able to see through clini-cal nuances and assure queries are clinically compliant.”

Colleen Stukenberg, MSN, RN, CMSRN, CCDS, clinical documentation management professional at FHN Memorial Hospital in Freeport, IL, and ACDIS advisory board member, says a CDI specialist’s characteristics should “include some basic ABCs, and then a few addi-tional supporting qualities which helps make the role more complete.” Stukenberg offers the following examples: » A strong clinical background of knowledge and expertise » Basic understanding of coding rules, MS-DRGs, etc. » Exceptional communication skills » Detail-oriented » Organized » Responsibility and follow-through

Kruse adds, “If you’re an introvert, this is not the job for you. You can’t be afraid to talk to doctors, even if they’re having a bad day.”

In addition, Shelia Bullock, RN, BSN, MBA, CCM, CCDS, manager of clinical documentation services at the

“ If you’re an introvert, this is not the job for you. You can’t be afraid to talkto doctors, even if they’re having a bad day.”

—Marion Kruse, MBA, RN



ACDIS welcomes newest Certified Clinical Documentation Specialists

ACDIS is proud to recognize and congratulate our most recent group of professionals to pass the Certified Clinical Documentation Specialist

(CCDS) exam. They are now free to begin using the CCDS credential after their name.

Members of this group took the test at one of our 170 assessment centers located nationwide. The exam is administered via computer, and

scoring results are provided immediately after the test. Please go to www.cdiassociation.com/certification for details or to apply.

Visit our Web site for continuing updates as ACDIS continues to build industry recognition of this important new certification.

» Hassan Alkhouli, CCDS

» Janet Anderson, CCDS

» Weddy Balmaceda, CCDS

» Sandy Barber, CCDS

» Edna Betances-Harold, CCDS

» Michelle Callahan, CCDS

» Yvonne Chapman, CCDS

» Mary Darrow, CCDS

» Theresa Davis, CCDS

» Stacey Egerbrecht, CCDS

» Fariba Fadaee, CCDS

» Karen Frosch, CCDS

» Janet Gentle, CCDS

» Crystal Hall, CCDS

» Kimberly Hamdani, CCDS

» Maureen Healy, CCDS

» Teresa Holliger, CCDS

» Deanna Holowczak, CCDS

» Jim Hughes, CCDS

» Julie Ketcham, CCDS

» Coral King, CCDS

» Sharon Krug, CCDS

» Lisa Krumrei, CCDS

» Julia Lewandowski, CCDS

» Deborah Lurie, CCDS

» Ron Martin, CCDS

» June Miller, CCDS

» Patricia Minto, CCDS

» Ophelia Moore, CCDS

» Tracy Peyton, CCDS

» Joan Reen, CCDS

» Catherine Relihan, CCDS

» Kristy Rice, CCDS

» Andrew Rothschild, CCDS

» Susan Schmitz, CCDS

» Amanda Suggs, CCDS

» Melissa Swierad, CCDS

» Maria Gilda Villanueva, CCDS

» Michelle Warner, CCDS

» Melissa Watkins, CCDS

» Helen Whitledge, CCDS

» Janelle Wissler, CCDS

University of Mississippi Medical Center in Jackson, says CDI specialists need to be quality-focused, have profes-sional pride and take ownership of their work, and be willing to work in a team environment, both inter- and intra-departmentally.

“They have to work with infection prevention, nurs-ing, wound care, physical therapy, dietary, etc., to enhance documentation,” Bullock says. She adds that a good CDI specialist “does not wear their feelings on their sleeve—they can take physician complaints and grumblings about regulations.”

Does this sound like a job for you? If so, I encourage you to take the next steps. Take a look at our Job Board at www.hcpro.com/acdis/jobs.cfm or feel free to ask further ques-tions of myself or our advisory board (www.hcpro.com/acdis/Advisory_Board.cfm).

In this issue of CDI Journal, on p. 16, we offer addi-tional staffing perspective from NHS Solutions, a CDI

recruitment agency based in Portland, OR. Also, in the October 2009 CDI Journal, Tamara A. Hicks, RN, CCS, CCDS, infection director and manager of care coordina-tion at North Carolina Baptist Hospital in Winston-Salem, and Lynne A. Spryszak, RN, CPC-A, CCDS, manager at Precyse Solutions, LLC, in Wayne, PA, offer additional thoughts in the article “Learn the top traits of a CDI specialist before hiring.”

Most of all, I wish you the best of luck in your decision. CDI is a challenging, but growing and rewarding, profession.

Take care,

Brian J. Murphy, [email protected]/639-1872, Ext. 3216



Improve predicted mortality rates through documentation

by Jon W. Arnott, MD, CMQ

An 89-year-old female is admitted to the hospital from home with a ST segment elevation myocardial infarction (STEMI). She also has stage 3 chronic kidney disease and refuses catheterization due to risk of dialysis. The patient enacts her living will. She is given appropriate medical ther-apy, but Sunday night at 3 a.m., her MI extends suddenly, and the blocked artery of the STEMI has re-stenosed. The woman passes away by 4 a.m.

not caught by the CDI team. The MS-DRG system seems to account for these events by design. These triplets leave an open door to many questions when we look at case mix relative to mortality.

It is reasonable to ask why a patient without a CC or MCC would expire. Other questions include: » Are these patients less sick than other patients who passed away? » Will their mortalities appear unjustified in the eyes of the Medicare Provider Analysis and Review or other database? » Will this event translate into a publicly available profile indicating that mortalities are higher than predicted? » Are physicians aware of their own profiles and how easy it is to ruin a profile?

Take a look at the chart below that depicts the relative weight of AMI depending on CC and MCC documentation. DRGs that are associated with a higher frequency of mortality yet are frequently underdocumented by the physician in regard to severity of illness include congestive heart failure, pneumo-nias, urinary tract infections, and malignancies.

Analyze dying process, not just cause of deathPhysicians live in a world of ambiguity. Outpatient

requirements do not recognize rule-out diagnoses, whereas inpatient documentation not only allows it but encourages its use. A similar paradox is found when we evaluate the manner in which physicians are allowed to document death.

Be prepared to apply bill holds to deaths that do not have MCCs. Everyone needs to realize that it is unreasonable to believe that any patient would die without a MCC. In fact, they don’t.

DRG chart

DRG # Description Relative weight

283 Acute myocardial infarction, expired w/MCC 1.6925

284 Acute myocardial infarction, expired w/CC 0.9111

285 Acute myocardial infarction, expired w/o CC/MCC 0.6408

The house officer enters the room, pronounces her death, and lists acute myocardial infarction (AMI) as the sole diagnosis. The chart is processed in HIM, and the busi-ness office drops a bill within 36 hours, to the delight of the revenue cycle metrics dashboard team.

It’s happened again—the mortality of a predictable mor-ibund patient of short length of stay damages another physi-cian’s profile. These deaths often tend to be assigned the lower of the MS-DRG “triplets” (without a CC or MCC). They tend to transpire overnight or on the weekends and are



Death certificate documentation does not allow for documentation of the dying process or the mode of death. Instead, death certificates require that a cause of death be noted (generally the principal diagnosis). Ironically, documenting the cause of death is not enough under the MS-DRG system. Instead, we need to focus on the dying process.

I serve as the senior vice president of quality and uti-lization management at my hospital. What I have learned while evaluating mortality charts with lower severity of illness is that there are three common elements to these events: 1. In these cases, it is easy to predict the impending demise

of the patient. To the clinician, it is obvious early on that the patient most likely will not survive.

2. All care provided by the facility is of an appropriate level of quality and utilization.

3. The patient passes away after a generally short length of stay—usually equated to a brief expiration note that, according to bylaws, suffices as the discharge summary.

Establish straightforward solutionsOne simple intervention can fix all these problems. The

medical staff must adopt a culture of documenting the dying process. Very simple entries will elevate the severity of illness to the maximum value under the MS-DRG. For example, CDI specialists should ask physicians to document the following: » Cardiac arrest » Respiratory failure » Hypotensive shock » Coma

CDI specialists need to educate physicians that the pri-mary diagnosis (e.g., AMI) would not be improved with a cardiac complication, but that respiratory failure would change the MS-DRG and improve predicted mortality measures.

Most physicians will perceive a request for the mode of death as another intrusion by the magnanimous CDI or case management department. But once a CDI specialist provides an explanation of predicted mortality measures, there is vir-tually no resistance.

The HIM department needs to be prepared to apply bill holds to deaths that do not have MCCs. Everyone needs to realize that it is unreasonable to believe that any patient would die without a MCC. In fact, they don’t. These patients have respiratory failure and cardiac arrest. They have hypotension. Most go into a coma. Inherently, the MS-DRG system penal-izes rushed documentation, but fewer scenarios are more damag-ing for a hospital and physician than the lack of documentation of the dying process.

Editor’s note: Arnott is a physician consultant at Wellspring Partners, a Huron Consulting Group Practice, based in Indianapolis. He is senior physician consultant at Physician Motivators (www.physicianmotivators.com) in Canfield, OH; senior vice president of quality and utilization management and cochief medical officer at Northside Medical Center in Youngstown, OH; and maintains a pri-vate office in Canfield. You can contact him via e-mail at [email protected].



Many CDI specialists struggle with the complication and comorbitity (CC) and major CC (MCC) lists due to their length, complexity, and specific documentation requirements. William Haik, MD, FCCP, director of DRG Review, Inc., in Fort Walton Beach, FL, spoke during the July 23, 2009, ACDIS audio conference “The CC and MCC MS-DRG Lists: A Clinical Review,” and offers the following tips for improving MCC recognition in the medi-cal record to ensure appropriate capture. (See the October 2009 CDI Journal for a discussion of the CC list.)

» Brain compression/herniation (348.4): In the absence of head trauma, if a physician documents compres-sion/herniation, or if he or she doesn’t document these terms but treats them with appropriate drugs (e.g., Decadron or Mannitol), and additional evidence appears on an MRI report, query the physician to determine whether it is a reportable diagnosis.

» Cerebral edema (348.5): The same guidance for brain compression/herniation applies to cerebral edema. Note this condition is frequently seen in patients with brain cancer or intracranial bleeding. Report this condition if the patient is treated with appropriate drugs (e.g., Decadron or Mannitol) even in the presence of trauma, since 348.5 is not an exclusion in the ICD-9-CM Manual. Find it referenced in Coding Clinic, third quarter 2009.

» Decubitus ulcer, stage III (707.23): This is defined as full-thickness skin loss. Although a wound care nurse can document the stage of the ulcer, a physician must document the site and type of the ulcer in order for a coder to report it (stage III and IV ulcers are MCCs; the site of the decubitus ulcer is not a CC or MCC but is required to report the stage).

Wound care nurses occasionally fail to document the

stage but describe it in clinical terms (e.g., “full-thickness skin loss”). If a wound care nurse describes the ulcer in a fashion that is similar to the terms in the inclusion list in the ICD-9-CM Manual, a CDI specialist does not have to query for the stage, and the coder may report the stage from this documentation. Note that if an ulcer is not reported as present on admission (POA) and develops dur-ing the patient’s stay, it will not be counted as a CC/MCC. However, if an ulcer worsens during a patient’s stay, a coder must report the highest stage of the ulcer. The ulcer is reported using a POA indicator of Y, and its progression/worsening does not affect POA assignment.

» Decubitus ulcer, stage IV (707.24): This is defined as a skin ulcer with necrosis of soft tissue down to the bone. The same guidance for stage III decubitus ulcers applies to stage IV ulcers.

» End-stage renal disease (585.6): This can be a con-fusing term for physicians, who often document it as stage V chronic kidney disease. If a patient is receiving dialysis, and a physician has not documented “end-stage renal disease” but has documented stage V chronic kidney disease, query the physician for ESRD. ESRD includes a glomerular filtration rate of < 15 ml/min.

» Gastrointestinal hemorrhage: If a physician links this diagnosis to an underlying diagnosis (e.g., gastritis, ulcers, or diverticular disease), it qualifies as an MCC. However, a gas-trointestinal hemorrhage unlinked to an underlying diagnosis is only a CC. Note that ICD-9-CM coding conventions do not assume a linkage between conditions; it must be docu-mented explicitly by the physician.

In addition, a patient does not have to be actively bleed-ing in the hospital in order for a coder to report a gastro-intestinal hemorrhage or other bleed; if he or she has bled recently/en route to the hospital, a coder may report a bleeding ulcer. See Coding Clinic, first quarter 1991 and sec-ond quarter 1992.

» Mallory-Weiss syndrome (530.7): Physicians may document an esophageal tear but not Mallory-Weiss syn-

Part two of a two-part series

Major complications and comorbidities, A–ZTips to obtain clinical documentation specificity

Telephone: 781/639-1872, Ext. 3711

E-mail: [email protected]

Questions? Comments? Ideas?

Contact Associate Director Melissa Varnavas



query a physician to report it as the principal diagnosis.” » Sepsis/septicemia: Sepsis is defined by the Systemic

Inflammatory Response Syndrome (SIRS) criteria, and accord-ing to Coding Clinic, sepsis only requires two of four SIRS elements for validation. However, Haik says this information is outdated and that current critical care medicine looks for several criteria in order to determine sepsis. “I would look for multiple abnormalities before I would query the physician about sepsis,” he says. Some abnormalities to consider include:

- SIRS criteria - Altered mental status - Oliguria (< 30 ccs per hour) - Hypotension (systolic blood pressure < 90 mmHg or a 40 mmHg drop from the previous normal blood pressure responsive to fluid resuscitation)

- Evidence of hypoperfusion (increase anion gap, reduced arterial pH, elevated lactate level, and reduced skin perfusion)

- Elevated biomarkers (C-reactive protein, procalcitonin, Interleukin-6)

- Unexplained hyperglycemia

drome. If a patient suffers an esophageal tear after forceful vomiting, usually presenting as an upper gastrointestinal bleed, query the physician for this diagnosis.

» Malnutrition, severe (Kwashiorkor, 260; Marasmus and severe NOS, 261; Other severe types, 262): Criteria for these types of malnutrition include the following clinical indicators: ideal body weight < 70%, pre-albumin < 5, albumin < 1.5. Note that these are very severe types of malnutrition. If a physi-cian documents emaciation with these or similar clinical indica-tors, and the patient’s emaciation is treated, a coder may report severe malnutrition.

» Renal failure, acute (584.x)/renal injury (nontrau-matic), acute (584.9): Physicians frequently document the terminology “acute renal insufficiency.” If this occurs, review the patient’s serum creatinine in the medical record and deter-mine whether the patient meets the RIFLE or AKIN criteria for acute renal failure or acute renal injury. If it does, query the physician for further specificity.

RIFLE stands for Risk, Injury, Failure, Loss, and End-Stage. You can find the RIFLE criteria at http://ccforum.com/content/10/3/R73/table/T1. RIFLE considers acute kidney injury as a serum creatinine change greater than a 2.0 change from the patient’s baseline. If the patient’s serum creatinine is greater than or equal to 4 mg/dl, it’s an acute rise of .5 mg/dl.

AKIN stands for Acute Kidney Injury Network, which contains newer criteria for acute kidney injury: a serum cre-atinine change greater than a 1.5 change from the patient’s baseline. If the patient’s serum creatinine is greater than or equal to 4 mg/dl, it’s an acute rise of 0.3 mg/dl.

“I prefer the RIFLE criteria as it is older and relates best to poor outcomes, such as death,” Haik says. “Also, unlike the AKIN criteria, it does not require correction for volume status.”

» Respiratory failure (acute and acute on chronic) (518.8x): Although Coding Clinic includes arterial blood gas (ABG) determinations to help determine the presence of acute respiratory failure, remember that acute respiratory failure is a life-threatening condition. ABGs alone are not strong enough criteria for a query.

“That’s really the underlying pinning of the diagnosis—the patient should be acutely ill and require close monitoring and supervision with aggressive therapy,” Haik says. “Not necessarily intubation, but aggressive care, before I would

“Not to worry—you’ll get used to it.”

Illustration by David Harbaugh



revenue management, 2714 Loker Avenue West, Suite 200, Carlsbad, CA 92010, 760/448-1063; [email protected].

Northern CA chapter: SheRee P. Garcia, RHIA, CHP, director, HIM services, UCSF Medical Center, 185 Berry Street, Lobby 1, Suite 2000, San Francisco, CA 94107, 415/353-2885; [email protected].

Central CA chapter: Contact Adriana van der Graaf, MBA, RHIA, CCS, CHP, national director, healthcare reform services integrated revenue management, 2714 Loker Avenue West, Suite 200, Carlsbad, CA 92010, 760/448-1063; [email protected].

Southern CA chapter: Contact Gloria Noell, RN, CCM, HCQM, CPUM, director of care management, Providence Little Company of Mary Medical Center, 4101 Torrance Boulevard, Torrance, CA 90503, 310/540-7676; [email protected]. Or contact Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS, senior director, case man-agement, Kindred Healthcare Hospital Division, West Region, 714/899-5020; [email protected].

Connecticut: MaryAnn Shanley, RN, clinical documenta-tion specialist at The Hospital of Central Connecticut, began meeting with other CDI specialists from the Constitution State in fall 2009. For information, e-mail [email protected] or call 860/224-5900, Ext. 2168.

In less than a year, ACDIS networking groups have grown from one or two in key locations to more than 25 local chap-ters across the country. They range in formality and official affiliation but share in their mission to bring quality CDI practices to their facilities and share lessons learned among their fellow professionals.

Some organizations have elected officials, whereas others meet casually after hours at local restaurants. Some challenge their members to become certified clinical documentation specialists, and others challenge members to share their facil-ity improvement processes with peers. ACDIS is thankful for all their efforts. Please reach out to these worthy groups and join them for a meeting. If you do not see your area listed below, contact Associate Director Melissa Varnavas, CPC, at 781/639-1872, Ext. 3711, or e-mail [email protected].

California: Three volunteers have stepped forward in the state of California to host four local groups. At present, the groups include:

CA chapter: Contact Dexter D’Costa, MD manager,clinical documentation program, quality improvement & patient safety, 1101 Welch Road, Suite A-3, Palo Alto, CA 94304, 650/723-5343; dd’[email protected]. Or contact Adriana van der Graaf, MBA, RHIA, CCS, CHP, national director, Healthcare reform services integrated

Local groups offer CDI specialists educational opportunities

Local ACDIS chapter legend

States with official ACDIS membership. Benefits include

discount national membership for local chapter members,

free products to raffle or share for local group use, continu-

ing education credits for CCDS credential, and more.

States with unofficial CDI specialist meetings. These

groups have either yet to become official members or

have decided to remain under another affiliated associa-

tion’s umbrella.

Looking for volunteers to help host initial meetings and

facilitate local chapter growth.



Delaware: Karen Frosch, CCS, manager of clinical doc-umentation improvement at Christiana Care in Wilmington, hopes to gather CDI professionals from the state that was the first to ratify the U.S. Constitution. You can contact her by e-mail at [email protected] or by phone at 302/733-4642.

Florida: The Florida ACDIS Chapter meets quarterly. For information, contact Sylvia Hoffman, RN, clinical documentation specialist at Tampa General Hospital, at [email protected] or by phone at 813/610-4818.

Georgia: Bonnie I. Epps, MN, RN, manager of CDI at Emory Healthcare, Inc., in Atlanta, and her compatriot James Howell Doster, RN, also at Emory in Atlanta, hosted the Georgia contingent of CDI specialists in November 2009 and have taken on a leadership role for the group. For information regarding upcoming meetings, contact Epps by phone at 404/712-4550 or by e-mail at [email protected].

Illinois: The Northern Illinois CDI Network started in 2008 and meets quarterly. The group currently includes

17 hospitals in the Chicago area. Contact Linnea Thennes, clinical documentation specialist at Northwest Community Hospital, Arlington Heights, at [email protected].

Indiana: Two groups in the Hoosier State plan to hold their first meetings in January 2010:

Southern Indiana: In southern Indiana near the Kentucky border, Dee Schad, RN, BSN, CCDS, CDMP, nurse manager at Clark Memorial Hospital in Jeffersonville, hopes to gather CDI professionals to network. Contact her at 812/283-2632 or by e-mail at [email protected].

Indianapolis: For those in a more central location, Susan Bradford, RN, BSN, clinical documentation specialist at Riverview Hospital, teamed up with Sandy Beatty, RN, BSN, C-CDI, clinical documentation specialist at Columbus (IN) Regional Hospital, to form a networking group there. For information, contact Bradford at 317/776-7285 or by e-mail at [email protected], or contact Beatty at 812/376-5652 or by e-mail at [email protected].

Louisiana: The New Orleans CDIS chapter meets every other month. For information, contact Melissa Mayer at [email protected], Royceann Fugler at [email protected], or Lindy Sells at [email protected].

Maine: The first meeting of Mainers took place in December 2009 thanks to the efforts of Theresa Davis, RN, clinical documentation specialist at Eastern Maine Healthcare Systems in Bangor. Contact her at 207/735-8340 or by e-mail at [email protected].

Maryland: The Maryland Hospital Association Clinical Documentation Improvement Workgroup meets bimonthly, the third Friday of the month, from 1:30–3 p.m. at the Maryland Hospital Association Headquarters in Elkridge. Contact Christine Mobley, RN, director of clinical documen-tation at Prince George’s Hospital Center, at [email protected], or James Nagel at [email protected].

Michigan: Sharin L. Cancilla, RHIT, CDS, at Botsford Hospital in Farmington Hills, MI, has been networking with a few local hospitals but hopes to connect with additional

continued on p. 14

Minnesota

The Minnesota ACDIS chapter started meeting in fall 2009 primarily

by phone, but in December a crew of nearly 10 arrived at Children’s

Hospital in Minneapolis. There were: Lynn Strand, Sharon Curtis, Becky

Johnson, Angie Boylan, Mark LeBlanc, Patti Smith, Kim Magee, Laurie

Banker, and Melson Elemino.



Nevada: Laura J. Werner, MSN, documentation special-ist at Carson Valley Medical Center in Gardnerville, wants to gather CDI specialists from the area for networking meet-ings. Due to the size of the state, Werner has started a networking blog, available at www.cdinformation.webs.com. You can contact her at 775/783-3064 or by e-mail at [email protected].

New England: Patty Spry, RN, clinical documenta-tion specialist at Emerson Hospital in Concord, MA, and Adrienne Gmeiner, RN, CCS, of Lawrence (MA) General Hospital, cochair the New England ACDIS chapter. The group, active for over a year, boasts more than 50 members. For information, e-mail [email protected] or [email protected].

New Jersey: The New Jersey ACDIS chapter meets monthly at the offices of Reimbursement Review Associates, Inc., in East Brunswick. For information, contact Deborah Gardner-Brown, RHIT, CCS, C-CDI, at 732/238-4511, or e-mail [email protected].

New York: Currently, three groups are meeting in the Empire State:

Albany: Lois Rubin, RN, BSN, CPUR, CCDS, lead clinical documentation specialist in the case management department at St. Peters Hospital in Albany, seeks to gather CDI professionals from the area for regular networking ini-tiatives. Contact her at [email protected].

Long Island: Adelaide M. La Rosa, RN, director of clinical documentation improvement at St. Francis Hospital in Roslyn, plans to gather CDI specialists from the various municipalities of Long Island. Contact her by phone at 516/ 562-6229 or by e-mail at [email protected].

Lower Hudson Chapter for CDI: Luanne Jennex, RN, clinical documentation specialist at Westchester Medical Center in Valhalla, teamed up with Deanna Holowczak, BSN, RN, clinical documentation specialist at Riverside Healthcare System in Yonkers, to network with those from the New York City/Westchester County area. For information, contact Jennex at 914/493-5861 or e-mail [email protected]. You can also reach Holowczak by phone at 914/964-4580 or by e-mail at [email protected].

CDI professionals for more formal gatherings in the future. Contact her at [email protected].

Minnesota: Michelle L. Callahan, RN, CDI lead spe-cialist at Hennepin County Medical Center in Minneapolis, seeks CDI specialists from the Viking State to join regular networking meetings. E-mail her at [email protected].

Missouri: Joann A. Agin, RHIT, regional manager, data quality at Carondelet Health in Kansas City, MO, is gath-ering CDI professionals in her area. For information, call 816/943-2115 or e-mail [email protected].

Nebraska: Michelle Clyne, RN, BS, CDI specialist at Good Samaritan Hospital in Kearney, hopes to gather CDI professionals in the Midwest region. For information, con-tact her at 308/865-7951.

Local groupscontinued from p. 13

Florida

The Florida ACDIS chapter took this photograph during its November

2009 meeting held at Shands at the University of Florida in Gainesville.

Although not everyone was identifiable, we recognized. : Sharon

Boulware, Nancy Lero, Wendy Walther, Susie Bennati, Virginia Bailey

Edna Betances-Harold, Tony Millican, Carol Harber, Carol Pikula, Nancy

Kelly, Dianne Martinez, Sylvia Hoffman, Charrington Morell, Lisa

Stearns, Donna Fisher, and George Hachey.



Southwestern PA: CDI groups in this area have meet regularly since May 2004. Originally meeting three times per year, the group now meets biannually. For information, con-tact Josie Pearson, BSN, RN, CDIS, at Memorial Medical Center in Johnstown, via e-mail at [email protected].

Texas: ACDIS is currently considering the formation of local groups in Texas. If you are interested in participat-ing in meetings, please e-mail ACDIS Associate Director Melissa Varnavas at [email protected].

Virginia: Gwendolyn Valiani, RN, BS, clinical documen-tation review specialist at MediCorp Health System in Fredericksburg, wants to connect with other CDI professionals from the 10th state in the Union. Contact her at [email protected].

Washington: The evergreen ACDIS chapter of north-west Washington state meets quarterly. For information, contact Jennifer Woodworth, RN, BSN, manager of clinical documentation improvement at Multicare Health System in Tacoma, by phone at 253/389-8493 or by e-mail at [email protected].

North Carolina: The North Carolina ACDIS chapter meets quarterly. The new format for the 2010 calendar year includes two full on-site meetings and two teleconference sessions. For information, contact Leah Taylor, RN, clini-cal documentation specialist at Iredell Memorial Hospital in Statesville, by phone at 704/873-5661, Ext. 3630, or by e-mail at [email protected]. You can also contact Jennifer Love, RN, director of clinical documentation improve-ment at Novant Health Care, Forsyth Medical Center in Winston-Salem, by phone at 336/718-6187 or by e-mail at [email protected].

Ohio: Two groups currently meet in the Buckeye State: Northeastern Ohio Canton Region CDI Network:

Kristine Cilona, RN, documentation specialist at Mercy Medical Center in Canton, hopes to connect with others from the state. Contact her at [email protected].

Southwestern Ohio ACDIS Chapter: Teri Sholder, RN, BSN, CPC, manager of documentation specialists in the clinical quality department at Kettering Medical Center in Dayton, hopes to gather specialists from the southwestern region to discuss documentation issues. Contact her at [email protected] or call 937/395-8462.

Oregon: The Oregon/SW Washington CDI Asso-ciation held its first meeting in September 2009 and plans to meet quarterly, with its next gathering slated for February. For information, contact Eileen Pracz, RN, clini-cal documentation specialist at Oregon Health & Science University in Portland at 503/418-4023 or by e-mail at [email protected].

Pennsylvania: Currently, there are three groups meeting:Northeastern PA: CDI programs are located in north-

east Pennsylvania and southern New York. For information, contact Sue Tiffany, RN, clinical documentation improve-ment supervisor at Robert Packer Hospital in Sayer, PA, and Corning Hospital in East Corning, NY, by phone at 570/882-6094 or by e-mail at [email protected].

Philadelphia: CDI specialists in the Philadelphia area interested in joining a local chapter can contact Debby Dallen, RN, clinical documentation coordinator at Albert Einstein Medical Center in Philadelphia, at [email protected].

New York

The following CDI specialists joined in Valhalla in December 2009 for

the first meeting of the Lower Hudson Chapter for CDI: GraceAnn

Magro, Christine Moore, Marybeth Devane, Dori Kessman, Kerry

Calle, Maryann Conti, Luanne Jennex, Deanna Holowczak, Margaret

Schroeder-Barr, Angela Sniffen, Patricia Bakos, Barbara A. Quigley,

Leslie Guido, Maureen Henry, George Kepler, and June Messina.



Editor’s note: ACDIS conducted a short interview with John Jager, president and CEO of NHS Solutions, Inc., and Scott Entinger, executive recruiter at NHS Solutions, regarding staffing needs and the expectations of the market.

What is it about the current state of healthcare that

makes CDI programs so important?

JJ: I equate the timing to a “perfect storm.” The healthcare industry has faced increasing costs for several years. The difference now is that the rate of increase over inflation is significant and widening. It is not sustainable, and hospitals are desperately looking for ways to cut costs or increase revenue.

Add to this the new regulations for Medicare reim-bursement and compliance that forced change in the process for hospital reimbursement.

Finally, the debates on Capitol Hill spurred by President Obama’s objective of reforming healthcare are highlighting once again the problems facing the indus-try. Taken together, the importance of a robust CDI program and quality initiatives has never been more important.

Regardless of the final outcome of healthcare reform, an effective CDI program is a significant part of the solution. CDI represents a clear growth area in the healthcare industry.

SE: Quality initiatives have come to the forefront of the healthcare industry due to political ramifications set forth by CMS, the 2009 inpatient prospective payment system, RAC [recovery audit contractors], and other CMS guide-lines, for example. Never mind the debate over healthcare reform that continues to be front-page news.

Hospitals are galvanized in their efforts to improve their quality of care and optimize reimbursement with their current payer mix. The costs of healthcare are ever increasing, and these costs cannot be continually absorbed for many hospitals and healthcare systems

without identifying new ways to effectively offset those costs. Implementing an effective, sustainable CDI program is a key element to addressing this growing challenge.

Why should a facility decide to implement a CDI

program?

JJ: Because this is such a clear trend in the industry and the payback is so obvious. With any new product or trend, you have early adopters that spot the oppor-tunity, believe it, and make the investment in it. We are past that point, although a large number of facilities are just now implementing CDI programs. Those that have adopted CDI programs early on now have data to prove how well it works. Most early adopters are now at the stage where they are increasing their investment. In fact, I do not know of a single facility we are working with that has cut back on their programs after running a pilot.

We have found that there are two main reasons why facilities do not jump on the proverbial bandwagon: 1. They are distracted with other facility problems

and have not been able to effectively consider this solution

2. They cannot afford the investment at this time

Unfortunately, both of these are short-sighted rea-sons that, in my opinion, must be overcome, or these healthcare facilities will fall even further behind. I see this similar to the 1990s when converting to enterprise-wide CRM accounting systems was a strategic decision for many companies. Today, many large corporations have completed the implementation and view the inte-grated system as a fundamental tool for the company. I believe that in five to 10 years, enterprisewide CDI programs will be a fundamental tool in most healthcare facilities.

CDI staffing segment

Examine political ramifications of CDI initiatives

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