ACDIS 2nd Annual Conference: Audio Recordings

Session Recordings from the 2nd Annual ACDIS Conference held on May 14-15, 2009 in Las Vegas, NV

Bring the ACDIS Conference to your office and train your entire team!
Add this resource add always have access to the 2nd Annual Association of Clinical Documentation Improvement Specialists Annual Conference. The set of recordings includes all sessions from the conference (18 total), with the exception of New analytics for new DRGs.

Teach your team to:

• Design a CDI program with the support of the medical staff
• Create a plan to ensure Recovery Audit Contractor (RAC) preparedness through CDI
• Construct optimal techniques for medical record review and appropriate queries
• Explain the new guidance and regulatory environment surrounding physician queries
• Recall greater clinical knowledge of complex diagnoses and conditions
• Use data mining and reporting in your CDI program
• Explain how CDI specialists can assist with documentation of quality indicators

Sessions Include:
AHIMA physician query practice brief: Maintain compliance with new guidelines
Gloryanne Bryant, BS, RHIA, RHIT, CCS

• Overview of AHIMA guidelines
• Written vs. verbal queries
• Identifying clinical indicators
• Documentation of written and verbal queries

Things you thought you knew about ICD-9-CM coding—but may not
Shannon McCall, RHIA, CCS, CCS-P, CPC-I

• Sequencing guidelines
• Coding Clinic references
• ICD-9-CM Official Guidelines

Identifying the clinical "hidden agenda" in the medical record
Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDI;Gamal Eskander, MD, MSPH, C-CDI

• Best practice techniques using case studies to review medical records, look for clinical clues, and identify the physician's potential clinical agenda
• Bringing the identified physician clinical agenda into the forefront through properly and appropriately constructed physician clinical queries

Case study: University of Tennessee Medical Center at Knoxville
Martha Collins, BSN, RN; Trey La Charité, MD; Lisa Peterson, BS, RHIA; Carla Stump, BS, RHIT, CCS

• CDI core team structure and function, including weekly core team "steering" meetings
• An explanation of individual CDI participant contributions
• Reviewing medical staff/resident education methods including physician queries, CDI lectures, pocket card creation, and service-line specific concurrent chart review “blitzes”

Critical chart analysis: How and where to identify opportunities in a DRG-based CDI program
Lynne Spryszak, RN

• Clues to identifying conditions that may affect (and more accurately assign) the primary diagnosis
• Where to look in the chart for "hidden information"

Restarting or revamping your CDI program: A case study
Catherine O'Leary; Colleen Garry, RN, BS

• Reasons why programs fail
• How to recruit & retain CDI specialists

Renal disease
Robert Gold, MD

• Anatomy and terminology
• Problematic terminology of acute kidney injury
• Clinical indicators in the medical record
• Common pitfalls in physician documentation
• Querying and obtaining specific documentation

Teaching physicians "What's in it for me"
Margi Brown, RHIA, CCS, CCS-P, CCS-P

• Establishing the initial contact
• Determining the focus of the presentation(s) and other efforts
• Avoiding potholes on the way
• Compiling numbers that impact the physician

Hospitals cannot live by DRGs alone: A focus on severity of illness and risk of mortality
Tamara Hicks, RN, BSN, CCS

• History of Clinical Documentation Management Program at North Carolina Baptist Hospital in Winston-Salem, NC
• How to apply CDI strategies to capturing severity of illness/risk of mortality
• Use of Six Sigma methodologies to improve the process

Forms and tools workshop
Gloryanne Bryant, BS, RHIA, RHIT, CCS
Developing forms and tools such as physician education posters, query forms, tip sheets, and reference cards can help a CDI department’s effectiveness. This session offers several examples of forms and tools.

The RAC experience: Use your CDI program to proactively address the RAC audits
Catherine O’Leary

• The value of complete and accurate documentation for areas of increased RAC scrutiny
• The physician query process – Posing a compliant query and the objective of “queries” in RAC prevention
• Including the CDI team in RAC preparation and ongoing self-audits

New analytics for new DRGs: Using business intelligence tools to support a measurement program for documentation and coding improvement
Dave Caplan

• New York-Presbyterian Hospital’s experience responding to the MS-DRG and ICD-9 changes, includinge reporting of POA indicators and hospital acquired conditions
• Describe creative approach to benchmarking MS-DRG and ICD-9 performance

What not to ask physicians
Robert Gold, MD

• Default codes that don't require a query
• Using other documentation in the record in place of a query
• Queries in the AHIMA practice brief and RAC auditor environment

Understanding Medicare's quality indicators
Kristen Geissler, MS, PT, MBA, CPHQ

• Background and timeline of Medicare's quality indicator reporting requirements
• Standard processes of concurrent and retrospective review and abstraction for quality indicators
• Specific quality indicators which lend themselves to concurrent review

A clinical documentation program success story five years after implementation
Terry Bakowicz, MS, RN; Jill Dressler, BSN, RN

• PinnaclefHealth System's clinical documentation program
• Getting physicians onboard within a teaching facility
• Technology trepidation: Making the CDI program work in a wireless world

Managing a clinical documentation department to excellence
Randi Ferrare, RN, BSN, MHA, M.Ed.

• Promoting growth opportunities for your staff
• CDI assignments and best practice strategies

Challenges in critical care: Sepsis and respiratory failure
William Haik, MD

• Sepsis–Clinical care elements and documentation:  when a physician documents urosepsis, bacteremia
• Respiratory failure–Clinical care elements and documentation: when a physician documents hypoxia, respiratory insufficiency
• Sequencing guidelines
• Formulating a succinct query

Physician documentation clarification: A coding, clinical, and patient safety perspective
Andrew H. Dombro, M.D.; Mario A. Perez, III, RHIA, RHIT, CCS, CCS-P; Melinda Tully, MSN

• Leading versus non-leading queries
• Clinical credibility tips and advice
• Clarifying coding specificity
• Improving documentation for quality measures

Q&A panel discussion

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