Health Information Management

Membership Update: Library materials offer ICD-10-CM/PCS queries, tips, and education

CDI Strategies, October 1, 2015

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The ACDIS Forms & Tool Library continues to be one of members’ most valued resource. If you haven’t visited this section of the website here’s a brief glimpse of what you may have missed.

  • Glenn Krauss, RHIA, CCS, CCS-P, CCDS, CDI manager at Washington Adventist Hospital worked with his medical and quality staff to create an audit tool to use when reviewing a record and providing feedback to physicians on the quality of their documentation, particularly in light of medical necessity requirements for inpatient admissions. Find it in the policies and procedure section of the library.
  • Krauss also donated a 40-plus slide presentation regarding ICD-10-CM/PCS implementation including a five-step implementation process. Find this in the ICD-10 Preparation, Education, and Queries section of the library.
  • Gloryanne Bryant, BS, RHIA, RHIT, CCS, donated a three-slide presentation regarding ICD-10-CM classification and documentation tips for asthma. Find it in the ICD-10 Preparation, Education, and Queries section of the library, too.
  • Paul Evans, RHIA, CCS, CCS-P, CCDS, regional manager of CDI and coding at SutterHealth in San Francisco, donated a sample ICD-10 sepsis query. It can be found in the ICD-10 Preparation, Education, and Queries section of the library.
  • Claudine Hutchinson, RN, CDI specialist at The Children's Hospital at Saint Francis in Tulsa, Oklahoma, donated a poster regarding additional specificity needed for pneumonia particularly in regards to treatment and causative agents. Find it in the physician education section of the library.
  • New York University Langone Medical Center's Mary McGrady, MSN, RN, CCDS and Murali K. Nagarajan, CCS, MB, BS, donated their example definition of postoperative respiratory failure following their summer 2015 webinar presentation "CDI and PSIs: Leverage Query Efforts to Capture Patient Safety Indicator Documentation". Find it under the query section of the library.
  • Cheryl Ericson, MS, RN, CCDS, CDI-P, CDI education director at ezDI, donated a sample query to demonstrate how CDI specialists can use queries as a method of clinical validation--to ensure the diagnosis documented in the medical record includes the necessary clinical indicators to support the diagnosis. Find it in the query section of the library.

The ACDIS Forms & Tool Library Review Committee invites member submissions. Query forms should be compliant with the latest ACDIS and AHIMA guidance and should have been reviewed for valid clinical indicators within the most recent calendar year.

To donate to the library email ACDIS Associate Director Melissa Varnavas at mvarnavas@acdis.org.

The Committee particularly seeks additional ICD-10-CM/PCS queries, CDI career ladder job descriptions and training materials, as well as policies and procedures regarding advanced CDI focus areas such as quality, pediatric, and outpatient efforts. 



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