by Penny Richards

As the coordinator for the Certified Clinical Documentation Specialist (CCDS) exam program, lots of folks ask me for CCDS exam prep tips. But I’m not a CDI professional—I don’t even play one on television—so I asked our CDI Education Director and Boot Camp instructor, Laurie Prescott, RN, MSN, CCDS, CDIP, CRC, for her expert advice.

“Some of getting ready for the exam is mental,” she told me. “If you’ve been working as a clinical documentation specialist for the minimum two years required [to sit for the exam], and you understand the role, you likely have the skills you need to pass.”

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A research brief from the University of Michigan's Center for Healthcare Research & Transformation (CHRT) suggests that hospital rankings, ostensibly designed to enlighten healthcare consumers, have morphed into a confusing array of metrics and methodologies that are now largely ignored outside of the healthcare echo chamber.

When coders can rely on the written diagnosis statement from a provider, it may negate all clinical documentation improvement efforts, according to an issue brief released by the Workgroup for Electronic Data Interchange (WEDI). In its 2017 Official Guidelines for Coding and Reporting, A. 19, CMS discussed code assignment and clinical criteria, specifically that the assignment of a diagnosis code should be based on the provider’s diagnostic statement that the condition exists. This Guideline, which has since been supported by the AHA’s Coding Clinic for ICD-10-CM/PCS, Third Quarter, has caused concern throughout the healthcare industry, especially in light of quality program reporting and auditing, WEDI says. The WEDI sought to clarify confusion regarding clinical documentation and ICD-10 coding.

Physician payment rates will increase 0.24% for 2017 compared to 2016, according to the 2017 Physician Fee Schedule Final Rule, released by CMS on November 3. This increase comes after application of the 0.5% payment increase required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and mandated budget neutrality cuts, says CMS.

This major final rule addresses changes to the physician fee schedule and other Medicare Part B payment policies. CMS finalized its proposals to pay for new telehealth services, including end-stage renal disease-related services for dialysis, advance care planning services and critical care consultations, and to expand the Medicare Diabetes Prevention Program model.

Note, please contact ACDIS Associate Editorial Director Melissa Varnavas if you any upcoming meetings in November or December at mvarnavas@acdis.org.

Q: If a complication is clearly documented as unavoidable or due to a complex situation, should it be coded even if an intervention was done to correct it? My concern is if a complication is unavoidable and has been documented as such, is there a good enough reason to not code it, similar to how we do not code a PSI if it was an inherent part of the procedure?

For example, the provider did a removal of malfunctioning pacemaker, and inserted a new pacemaker. Ending up with pneumothorax is never inherent to this procedure. The physician, however, documents that the patient had extensive adhesions, and a complicated anatomy, due to which this unfortunate complication happened, and that it was unavoidable. Are any complications that the physician says are unavoidable to be considered inherent to procedure, and not be coded?

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The following white paper demonstrates the importance of implementing a career ladder and/or incentive program for your CDI staff. It provides sample models of each that hospitals can consider and adapt for their own use.

Please register for ACDIS Quarterly Membership Conference Call on Nov. 17, 2016 1:00 PM EST. This call features a special roundtable discussion with the ACDIS advisory board leaders.