CDI Workbook: Investigating Complex Cases and Formulating Queries

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CDI Workbook: Investigating Complex Cases and Formulating Queries

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CDI Workbook: Investigating Complex Cases and Formulating Queries

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CDI Workbook: Investigating Complex Cases and Formulating Queries

Sheila Duhon, MBA, RN, CCDS, A-CCRN

Reviewing cases and formulating queries is the central work of a clinical documentation improvement (CDI) professional. However, different chart and different review focus change the way a CDI specialist conducts their review.

CDI Workbook: Investigating Complex Cases and Formulating Queries provides CDI professionals, at all levels, with the practical tools and tips needed to hone their CDI reviews and skills. Readers will walk through in-depth case scenarios with author Sheila Duhon, covering the most frequent documentation trouble spots and examining theoretical records through the lens of different programmatic focal points. Following each case scenario, you’ll find query suggestions and discussion ideas related to why a CDI specialist would query for certain diagnoses and tips for physician CDI education.

Whether you’re reviewing for CC/MCC capture, quality measures, risk adjustment, etc., the Workbook has something to teach you.

The Workbook provides:

  • Clinical case study reviews for all levels of CDI experience
  • Advice for determining record prioritization depending on CDI program goals
  • Tips and tools for compliant query creation
  • Physician education ideas targeted for specific diagnoses
  • Tools for evaluating CDI program outcomes and CDI staff effectiveness

About the Author:

Sheila Duhon, MBA, RN, CCDS, A-CCRN, is national CDI director, educator, performance management and innovation division for Tenet Healthcare Corporation. She’s been involved in CDI since 2006, and finding the position offered a career in which she could continue her love of learning.

Published: September 2018

Page count: 148
Dimensions:8.5 x 11
ISBN: 978-1-68308-806-6

Table of Contents

About the Author
Chapter 1: Core CDI Program Practice and Competencies

  • Historical perspective 
  • Mission statements 
  • Steering committees 
  • Organizational reporting structure 
  • Hiring and training new CDI specialists 
  • CDI medical record review process 
  • Measurements of success 
  • The value of a robust CDI program 

Chapter 2: Physician engagement and education 

  • A comprehensive team approach 
  • The CDI specialist 
  • The physician provider 
  • Engaging physicians 
  • The physician advisor 
  • The physician advisor’s role in CDI 

Chapter 3: A Compliant Query Practice 

  • Historical perspective 
  • Authoritative guidance 
    • AHIMA 
    • ACDIS 
    • HIPPA and the Four Cooperating Parties 
    • The False Claims Act and the Stark Law 
  • The query process 
  • ACDIS/AHIMS joint brief, 2016 
  • The AHIMA 6 
  • What is a leading query? 
  • What is a compliant query? 
  • Query storage and retrieval 
  • The verbal query versus the written query 
  • There’s no correct or incorrect response to a query 
  • The concurrent query process 
  • The retrospective query process 
  • When a provider refuses to respond to a query 
  • Authorized persons who can query a provider 
  • The query format 
    • Open-ended queries 
    • Multiple choice queries 
    • Yes/no queries 
  • Writing effective queries: Best practices 
    • The “TRIC” to query success 
    • The “dos” for an effective query process 
    • The “don’ts” for an effective query process 
  • Developing an effective

Chapter 4: Case Studies: Exercises in the Practical Application of the CDI Review Process and Query Development 

  • Neurology: Altered mental status 
    • Case study 
    • Sample query 
    • Discussion 
  • Hematology: Anemia 
    • Case study 
    • Sample query 
    • Discussion 
  • Cardiovascular: Heart failure 
    • Case study 
    • Sample query 
    • Discussion 
  • Nephrology: Chronic kidney disease 
    • Case study 
    • Sample query 
    • Discussion 
  • Procedure: Debridement 
    • Case study 
    • Sample query 
    • Discussion 
  • Nutritional: Malnutrition 
    • Case study 
    • Sample query 
    • Discussion 
  • Multiple conditions: Acute kidney injury, pneumonia, respiratory failure, and sepsis 
    • Case study 
    • Sample queries 
    • Discussion 
  • Multiple conditions: neoplasm, malnutrition, and renal condition 
    • Case study 
    • Sample queries 
    • Discussion 

Chapter 5: Leading and Managing a CDI Program 

  • CDI program evaluation 
  • CDI program leadership 
  • CDI program management 
  • CDI specialist development 
  • Measurement of CDI program goals 
  • The big data, the little data, and the “intangible” data 
  • Conclusion 

Add Association of Clinical Documentation Integrity Specialists (ACDIS)

$20 discount on your one-year ACDIS Membership will be applied at check out.

ACDIS is a community of CDI professionals who share the latest tips, tools, and strategies to implement successful CDI programs and achieve professional growth.

ACDIS members receive: 

  • Advocacy and leadership from a peer-elected ACDIS Advisory Board, including peer-reviewed Position Papers and White Papers.
  • Weekly tips, news, and strategies in our e-newsletter, CDI Strategies
  • In-depth news and regulatory information, clinically-based articles, case studies on building successful CDI programs, and membership profiles in our bi-monthly electronic journal, the CDI Journal
  • An opportunity to network with peers and colleagues in the ACDIS Forum
  • Access to live and archived quarterly conference calls, hour-long networking discussions and an open Q&A with the ACDIS Advisory Board
  • Helpful tools accessed in our electronic Resource Library, including sample queries, policies, and archived conference presentations
  • Two free job postings a year, discounted additional posts, and the ability to post your resume on our Career Center
  • Opportunities to participate in an Official ACDIS Local Chapter in your area, under the leadership of the Chapter Advisory Board
  • Discounts to the annual ACDIS conference, CCDS certification, and CDI Boot Camps

To explore all that ACDIS has to offer, please
visit the ACDIS Web site.