Off the Record with Brian Murphy

I'm recently back from the 2025 ACDIS national conference, and as usual flush with the latest in CDI trends, education, and breaking news. And right at the top of my takeaways is a seemingly innocuous classification with big ramifications: admit type. What makes this a big deal? Some hospitals appear to be playing a bit fast and loose with  guidance from the National Uniform Billing Committee (NUBC) in order to classify surgical admits as “urgent” rather than the more accurate “elective.” Doing so removes them from certain PSIs that negatively impact quality metrics and indirect revenue. My guest is Penny Jefferson, manager of clinical documentation integrity at UC Davis Health. Penny co-presented the session with Cheryl Ericson at the ACDIS conference. On this show we discuss: What is admit type, why is it important, and common misunderstandings (admit type is very different than admit status--IP/OP/observation) Who is the NUBC, and what are the current rules as they stand around elective, urgent, and emergent? Compelling data—deidentified, but real—presented at ACDIS that shows what appears to be clear gaming by some healthcare organizations of the assignment of admit type, specifically opting for urgent over elective The dramatic impact this seemingly small change can have on quality scores: Reclassifying an elective procedure as urgent effectively circumvents PSI exclusions, allowing the case to be excluded from elective-only quality measures, such as PSI 10, 11, or 13. Possible solutions including Penny's ongoing work with the NUBC and request for additional rigor Optimal way to ensure admit type accuracy in the current climate, from use of coding or CDI staff to additional training for admission staff Why is her boss Tami Gomez so awesome, and Penny's selection for the Off the Record Spotify playlist  For additional reading Inconsistent ‘Admit Type' Reporting May Inflate Hospital Quality Scores, by Nina Youngstrom/Report on Medicare Compliance: https://compliancecosmos.org/inconsistent-admit-type-reporting-may-inflate-hospital-quality-scores  

Until about 6-7 years ago A.J. Hegg had little idea what the acronyms CDI or UM were, much less what they did or how they helped hospitals.  Today the Essentia Health hospitalist is leading a new physician advisor program and making a big impact on his organization. Both from a quality and financial perspective, but also on the personal lives of a diverse team of physician advisors who have managed to incorporate life balance into their work. Listen in as we cover: Hegg's origin story into CDI, fueled (or perhaps pushed) by director Tracy Boldt  His role today—CDI vs. medicine, and division of responsibilities Essentia Health's physician advisor program—services covered, scope of work, and core responsibilities including UM and CDI simultaneously Bringing back old-school CDI as it was once practiced (and still is in some corners)—at the elbow clarifications, conversations, provider education. And how it all meshes with Essentia's existing CDI team. Metrics, assistive technologies, and high-level dashboard Who the team is and how it functions—shift work and task based, structured for work-life balance and an emphasis on positive culture Obtaining organizational buy-in and high-level ROI A favorite hazy memory from the Encore casino in Boston, September 2021 ACDIS physician advisor exchange... 

Outpatient CDI is not a traditional discipline—and so it stands to reason that its practitioners don't always hail from traditional backgrounds. One such person is Glenda Bocskovits. I'd call her a former transcriptionist, but she still practices that craft with the Mayo Clinic. But Glenda has since expanded her career into cutting edge practice as an outpatient CDI specialist with Catholic Health. We get into Glenda's unique career path, the obstacles of breaking into CDI as a non-clinician, and address the eternal question: What is the ROI of OP CDI? We cover the following topics:  Transcription: That's still done? It is (hear why). The ROI of outpatient CDI  Catholic Health's thorough process of OP CDI chart review: Prospective, current/pre-bill, and retrospective Common conditions requiring clarification and what continues to trip up providers A day in the life of: What Glenda's job entails Obstacles of getting into CDI as a non-nurse and strategies for landing elusive interviews Glenda's career motivations and song selection for the Off the Record Spotify playlist 

Social Determinants of Health, or SDOH, are a buzzword these days—but often little more. We acknowledge their importance, but actual progress on capture (and subsequent patient support) has been slow. To be fair real barriers including technological limitations and limited financial incentives stand in the way. But my current guest understands better than most the major role SDOH play in patient health. He and his organization have developed a digital tool to facilitate capture and improve the lives of patients in their community. They're making a difference. Dr. Pablo Buitron de la Vega is Assistant Professor of Medicine, Medical Director, Preventive Medicine Residency, and Clinician Lead for the THRIVE Social Determinants of Health Program at Boston Medical Center / Boston University School of Medicine. A native of Ecuador, he's made SDOH his mission. On this show we cover: Dr. de la Vega's long journey from Ecuador to U.S. physician, the obstacles he overcame, and how the experience shaped his mission as a provider Defining SDOH and common examples in his line of work as a Boston physician Basics of capture in ICD-10 and what makes SDOH difficult to collect Boston Medical Center's SDOH capture tool, THRIVE: What it does, tangible benefits, and how your organization can get access Low-tech strategies for SDOH capture you can implement today Dr. de la Vega's National Institutes of Health (NIH) grant to develop a triage tool to help address patients' unmet social needs

I've been in the coding and CDI worlds since 2004, and in that time watched the rise of Facebook, YouTube and other social media. And as early 2011 or so I began to wonder, will anyone pair these two together? When will see our first social media creator in the world of medical coding, making it his or her full-time gig? I'm pleased to say that the day has arrived. Victoria Vo is a Medical Coding Educator, Auditor, YouTuber, Entrepreneur, and founder of Contempo Coding, LLC. Her YouTube channel has 187,000 subscribers and she's created close to 600 videos, some of which have racked up more than half a million views. If you've met or seen Victoria you know this did not happen by chance. She's a natural educator, charismatic and personable. But she's also very knowledgeable about coding, passionate about the profession, and an outspoken industry advocate. We get into all this and more in a very social episode of Off the Record. On this show we discuss: Victoria's coding origin story Contempo Coding, the business and what it's about Becoming a creator: Challenges and early side-hustle successes, timeline to earning her first $, and how she left coding to become full-time entrepreneur Three times she was recognized as a coding celebrity outside of AAPC conferences Advice for someone who wants to pursue content creation A joint ChatGPT rant (we both sound off on how we use it, and see it abused) What makes for a good coding professional Other fun stuff including her top resources and Off the Record Spotify playlist selection

Even if you've never seen The Godfather, you've probably heard its iconic line: “Just when I thought I was out, they pull me back in!" That certainly applies to Sheila Duhon, National Director of Clinical Documentation Integrity for Steward Health Care. A year ago Sheila was headed toward semi-retirement, but changing events on the ground in the beleaguered healthcare system prompted her to get back into the game with her old organization. Sheila is a 2022 CDI Professional of the Year award winner, a published author and passionate educator, but above all possesses a strong moral compass and a willingness to do what's right for her CDI team and the patients they serve—one which has served her well in a tough spot. On this show we cover: Sheila's second act in CDI, from semi-retirement to full-time leadership role The cloud over Steward: How she puts that aside and focuses on the task at hand Her formative experiences as a nurse thrust into the ICU at age 19 What makes for a good CDI educator, including her story of a challenging first educational session for a group of providers CDI as she sees it: A clarification that hospitals still miss, pros/cons of the current state of the profession Timeline toward retirement part 2 and final words of advice. Plus of course Sheila's selection for the Off the Record Spotify playlist.

We all get excited—and rightfully so—at the rapid advance of clinical medicine. New treatments, therapies, and drugs save lives. But when you work in the revenue cycle, you know that payment mechanisms can significantly lag new technologies.When codes don't exist, or reimbursement is woefully inadequate, you have to take action. Petition, sometimes at the highest levels of government.Jugna Shah is fighting for improved coverage and reimbursement for CAR-T and other cell and gene therapies, a trip that recently took her all the way to Capitol Hill. On this episode she talks about exciting work underway to improve healthcare accessibility and reimbursement, shaking hands with popular politicians, and of course some can't miss documentation and coding tips.On this show we cover:Jugna's mission and the mission of Nimitt ConsultingCAR-T and other cell and gene therapies: Current reimbursement mechanisms, insurance and coverage issues, and regulatory guidanceJugna's advocacy efforts at the recent White House Cell and Gene Therapy ForumWhat came out of the Forum and what's next given the recent change in administrationWhat hospitals can do today to receive appropriate reimbursement for these life-saving therapies (she offers up some great advice on setting appropriate charges, citing the regulations)Where are we with drug administration (i.e., coding of injections/infusions)

We hear about lawsuits and false claims acts regularly, but did you know that many of these begin with someone working from inside the organization? Calling out bad behavior or noncompliance, sometimes again and again without being heard—before deciding to call on a third party for help? You might have seen the recent headlines about New York insurer Independent Health, which agreed in December to pay $100M to settle allegations it had upcoded claims to inflate Medicare Advantage payment. But did you know the basis of the lawsuit was a whistleblower, and 12 years in the making? My guest on Off the Record knows this very well. Mary Inman is a Partner at Whistleblower Partners LLP, and Head of International Whistleblower Practice for the firm. She also served as legal counsel in this very case. I continue my “law and coding” start to 2025 with a fascinating guest and topic. On this show we discuss: Who/what is a whistleblower, and the concept of qui tam The mechanics/process of a whistleblower engaging a lawfirm: Are they working for their employer throughout reporting, discovery? Is gathering evidence to support their case without employer knowledge illegal? What happens to a whistleblower who wins—or loses? How much can they stand to make, and is their career over? New DOJ whistleblower project to encourage additional reporting What some whistleblowers get wrong/false report or misunderstand What hospitals/healthcare organizations can do to lessen the risk Mary's Off the Record Spotify playlist selection (I was disappointed it was not Judas Priest's Breaking the Law)

Medicare Advantage. It's everywhere you turn. From upcoding to denials, the huge and growing program—which now covers more lives than traditional Medicare, but is increasingly the target of local and federal scrutiny and a stream of endless OIG audit reports—seems to be in the news daily. In a sea of online anger and noise, there's a few voices of reason, reminding us about the regulations and guidelines and how MA should be conducting itself—at least in theory. One such person is Richelle Marting. Richelle is an RHIA and a JD and owner of a host of coding credentials besides. As a Healthcare Reimbursement Attorney and Founder of Marting Law, LLC, she brings a unique legal viewpoint to medical coding, coverage, and payment. She knows what regulations bind Medicare Advantage plans—and how these are often skirted. On this show we cover: • Richelle's start to 2025, personally and professionally • What MA plans must cover and pay for, by law • Prior authorization • Under which circumstances MA plans can use internal coverage criteria • How MA plans game the system: three sneaky tactics you won't want to miss • The latest on automated denials/use of AI • Richelle's answer to the question: Medicare Advantage: Yay or Nay? • An interesting new year's resolution and latest addition to the OTR Spotify playlist Richelle's desktop MA policy links: Governing rules for Medicare Advantage: Code of Federal Regulations 42 Part 422: https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-C Final rule for MA plans (April 2023), 4201-F: https://www.federalregister.gov/documents/2023/04/12/2023-07115/medicare-program-contract-year-2024-policy-and-technical-changes-to-the-medicare-advantage-program Medicare Internet-Only Manuals: https://www.cms.gov/medicare/regulations-guidance/manuals/internet-only-manuals-ioms Medicare Advantage 2026 proposed rule: https://www.federalregister.gov/documents/2024/12/10/2024-27939/medicare-and-medicaid-programs-contract-year-2026-policy-and-technical-changes-to-the-medicare

Here we are, at the end of the year. And the end of another season of Off the Record. For reasons that will soon become clear, I wanted to wrap up 2024 by pushing myself out of my comfort zone. Because this episode is about personal growth. So here I am, doing my first ever solocast. I bring you the Top 5 lessons learned over the year of Off the Record. These apply to mid-revenue cycle leaders, our core audience for #OTR, but they're broad enough for anyone to adopt. This is a tidy episode, just 26 minutes of distilled wisdom from several guests that I was honored to host. Enjoy, Merry Christmas and Happy Holidays, and I'll see you in 2025.

Last month I wrote a post about the four stages of a career, using the analogy of seasons. I was inspired by the wonderful fall weather I was experiencing while on a walk here in New England, but also by changes I have been experiencing in my life and how these have caused me to re-evaluate what's important in my career. The post got a good reaction, including from Nicole Fox, Associate Chief Medical Officer, Medical Director of Pediatric Trauma, Medical Director of CDI, at Cooper University Health Care. Which led to this show. Nicole and I are in the “fall-ish” of our careers. Which might sound like we're getting ready for pasture, but not really. I'm 51 and Nicole is 48, so we have many more years to work—but our priorities are changing. You might say, they are better aligning with the new people we are becoming, as human works in progress. Nicole has done a lot with career coaching, both as recipient and mentor, and we get into all that on today's show—and bare our souls a little bit about what is holding us back. This was a terrific conversation with an amazing person and I suspect you'll enjoy it, and maybe come away a bit more reflective about your own career and priorities. On this show we discuss: • An update on Nicole's work as a pediatric trauma surgeon and hospital executive—and the need for changes • Her experience with a career coach and what she learned about herself • Career “saboteurs”—how do you discover them, and what can you do to diminish them? I highly recommend taking the free assessment linked below (my top 3 saboteurs are avoider, hyper achiever, and pleaser) • Is it possible to shape your career, and how does that look in practice? • The “seasons” of a career and using it as a framework for discovering what is most important (with an emphasis on the fall season) • Nicole's forays into coaching and mentorship, and prioritizing health and work-life balance in a demanding clinical career Show notes Four stages of a career: https://www.linkedin.com/posts/brian-murphy-13800b11_i-love-the-fall-especially-here-in-new-england-activity-7253050994937212932-2QFY? Career saboteurs assessment: https://www.positiveintelligence.com/saboteurs/

With 23 years and counting in CDI, Rhoda Chism has seen a lot. The rise of new regulations and reimbursement mechanisms, and the advent of new technologies that have radically transformed chart reviews.  Rhoda has not only weathered these changes and navigated the turbulent waters, but remains as warm and personable, and pro-person, as you will ever meet.   But not anti-technology.  Today she is the Director of Clinical Excellence and Adoption for the software company Iodine, a new position she's held for just two months. But I think she could be called Chief People Officer.  We get into the blending of human and machine, discussing the following:  Rhoda's journey into healthcare and nursing at the tender age of 19.  The transition from bedside nursing to CDI in 2001  Melissa Varnavas and the lasting impact of a simple message of encouragement and belief  Using authentic, personal stories to communicate difficult CDI concepts and education, including heart failure and AKI  How technology has radically transformed CDI over the last two decades  AI driven technology as human amplifier, not replacement, and the importance of emotional intelligence in CDI work  Career advice for young professionals in a world of rapid change 

Karen Elmore is living in denial(s).     Her job as Senior Clinical Documentation Quality Coordinator for BJC Healthcare involves a daily battle against a never-ending tide: Payers denying diagnoses on the perceived basis of lack of clinical support. Recently she's had to deal not only with human payers, but artificial intelligence denials as well.    Karen's organization has worked hard to stem this never ending tide, and found some success with uniform organizational clinical guidelines and consistent education and engagement.     We talk denials, appeals, preventing future denials through provider education, and  Kansas City Chiefs football (still undefeated as of publish date), on this episode of Off the Record.    On this show we cover:    Karen's unique role as program manager for CDI at BJC, including responsibilities for physician education, engagement, and denials prevention  Typical denials for sepsis, respiratory failure, and malnutrition: What payers are using for ammunition  What payers are the worst offenders, and particularly creative (and egregious) tactics  AI denials—how do you spot them, and combat a machine?  Provider engagement strategies and relaying denials back to physicians  Legitimate reasons for denial and ongoing documentation shortfalls  Karen's Kansas City Chiefs obsession—inside an average Sunday in the Elmore household (it's crazy) 

Following is part 2 of our interview with Revka Stearns, who joined us on Off the Record to provide an update of her first eight months on the job as a new inpatient coder. If you haven't listened to part 1 I'd recommend starting there, since we pick up mid-conversation. On this show we cover: The mechanics of working as a remote coder. Workplace setup and helpful recommendations Dealing with the physical challenges of working at a desk all day and breaking up the routine Unexpected consulting work coming her way ... from Canada! Unfiltered conversation about social media. Revka's take on the social media landscape, dealing with negativity, dispelling persistent myths (there's no coding jobs! It's all being outsourced! Yes there are, and not it isn't—Revka is proof), and being a consistent, positive, and helpful online presence. Keeping sane through work-life balance, and her latest Off the Record Spotify playlist entry

Back in January I hosted newly minted medical coder Revka Stearns. For someone so new to the industry, Revka has made a big impact by the act of sharing--documenting her journey in detailed and open fashion on LinkedIn and Facebook, and a half dozen podcasts and programs. At the time she was on the show Revka had literally been on her first job for about 3 weeks. Eight months later I asked her to come back for an update and share her successes, challenges, and unexpected side-ventures. Revka has many strengths—smart, hardworking, diligent--but one of them is effective use of social media, creating a model for how I like to see these platforms used (and unfortunately often aren't). But she's also had her share of struggles. Coding is hard. This was a bit of a longer interview so I split it into two parts. On part 1 we cover: Eight months on the job as a first-time medical coder Specific challenges she's encountered, including: Making sure the organism causing an infection is clearly linked to that infection through documentation Ensuring documentation is carried through to discharge, beyond the provider just copying and pasting Recognizing query opportunities The reality of learning: Taking one step forward and two steps back Most rewarding aspects of the job What she knows now that she wished she knew back in January

With 25 years' experience in medical/surgical, critical care, and emergency department medicine, Tonya Motsinger has seen her share of crises.   COVID-19 was a crisis of a far larger scale.  The pandemic wreaked havoc not only on patients, but her CDI department, resulting in staff shortages.  Today OhioHealth's System Director of Clinical Documentation Integrity has come out on the other side stronger. You might even call her, a survivor.   We discuss lessons on staff retention, remote onboarding, and some great work she's done to improve her organization's Vizient clinical quality rankings. On this show we cover:  OhioHealth's CDI department including basic KPIs and department objectives, and Tonya's role as System Director.   Impact of the COVID-19 pandemic and department staffing devastation  Putting things back together: Salary increases and short-term weekend coverage plan  Challenges of remote orientation for new CDI staff  All things Vizient: New Vizient calculator, CDI review nuances, and impact on actual organizational quality Onboarding a new hospital that's never had a CDI program (I know, such places apparently still do exist)  Being a new grandmother and her addition to the Off the Record Spotify playlist 

Bridging the gap between clinical and financial worlds is the goal of CDI and coding, but it's much easier said than done. One way to reconcile this schism is through data—objective numbers that don't lie, but can speak to both sides of this seemingly irreconcilable chasm. Associate Director of Coding and CDI at Yale New Haven Health (YNNH) Leif Laframboise believes in the power of data and uses it to structure the work of the coding and CDI departments under his oversight. But he marries that with a candidness and leadership style I admire, and an inner strength that has allowed him to persevere with a disability that might have ended the career of another. Leif is not just a data lover but an all-around good dude that I got to know a little bit during my ACDIS days, and I'm pleased to have him on this episode of Off the Record. We discuss: • An overview of the CDI and coding departments at YNNH • Broad departmental KPIs, with present on admission as a north star in a sea of competing quality programs • YNNH's unique reporting structure to both finance and the chief medical officer, and how that works in practice • Why and how Leif embraces data—what he looks for, how he uses it to drive improvements, educate providers, and focus his team's chart reviews • His thoughts on how CDI and coding must evolve with changing times • His disability and how he's worked around it in a visible leadership role • Our first Foreigner selection on the OTR Spotify playlist (about time)

Robin Jones moved to Florida at the tail end of 2017 to pursue a burgeoning career in CDI. And ever since has done nothing but climb the professional ladder. Leaving behind her home in Cincinatti Ohio and a decorated career in CDI at Mercy Health, Robin started over as Division Director of CDI at AdventHealth West Florida in November 2017. A few years later she was promoted to Director of Clinical Excellence. You might recall that she joined me for an episode of Off the Record in November 2022 to talk about this change. Three months ago she was promoted again, this time to Vice President of Clinical Excellence & Education. And I knew it was time for a return visit. We get into her flourishing career and the broader CDI program at AdventHealth West Florida on today's Off the Record. On this show we cover: Promotion to VP of Clinical Excellence and Education and what it entails New VP level leadership responsibilities, and what new skills Robin had to cultivate to meet them What she had to give up to accept this new role, and the challenges of delegation Commitment to hybrid onsite/remote CDI and a unit-based model of coverage Winning a Leapfrog Emerald Award, AdventHealth's emphasis on public report cards and how CDI can make an impact Retaining and building the workforce of tomorrow

Our two-part “Podcast on the Pirogue” miniseries concludes in this installment of Off the Record, recorded live in the backwoods of Pierre Part, Louisiana.  Here I wrest back my traditional host seat (after the takeover in part 1) and interview Jason Jobes, Senior Vice President of Solutions at Norwood, and Dr. Robert Oubre, aka, The Doctor of Documentation. We discuss their newfound roles as entrepreneurs in the throes of growing a business.  Jobes is building the Solutions arm of Norwood, driving new consulting engagements and managed services, while Oubre has launched a series of physician e-learning CDI courses and (most recently) a new online community. We cover lessons learned, mistakes made along the way, proudest achievements, the importance of mentorship, recommended resources, and ultimate goals and aspirations.  If you are looking to start your own business, take up a side hustle, or build your personal brand in the mid-revenue cycle, this is one you'll want to listen to. Some great talk with two good dudes “BS-ing on the Bayou” with occasional lapses into profundity.  Enjoy! 

I've hosted the Off the Record podcast since September 2022. Over that time I've recorded dozens of interviews with scores of great guests, with episode 50 right around the corner. But I've never had the microphone turned on myself. Until now. This past April I was hanging out at the ACDIS conference with my colleague Jason Jobes and Dr. Robert Oubre, CDI physician advisor at St. Tammany Parish Hospital. There the three of us hit on the idea of a podcast recorded in person in Louisiana, where both Jason and Robert live. What would we talk about? Dr. Oubre decided it was time for me to go under the spotlight. On this episode we talk about my unlikely career path from odd jobs and journalism to healthcare and Director of ACDIS, and eventually here to Norwood. It's a revealing interview that made me sweat—and not just from the Louisiana heat. So, I hope you enjoy this unconventional and very unscripted episode about my origin story, the early days of CDI and ACDIS, and some personal lessons learned along the way. Pardon the sound quality. You will hear the authentic sounds of the Bayou on this episode. We recorded in Jason's screened porch in Pierre Part, best known as home of the reality TV show Swamp People. No guests were harmed by alligators during this recording.

I have to say it's very inspiring being around my guest on today's show. Prior to this episode of Off the Record I had never met Keisha Wilson ... and within minutes I felt like we were friends. Something about her warmth and spirit that grabbed me right way. I hope you will feel it too. Keisha is an entrepreneur, the founder and CEO of KW Advanced Consulting. But she's also a volunteer and a mentor to many in the coding industry and beyond. And she's made a niche for herself in telehealth, recently presenting a well-received session on the topic at the recent AAPC National Conference. We talk about all this and more on the episode, covering: Keisha's unique life journey into the U.S. and eventually healthcare and coding Getting pushed by life circumstances to start her own business—much earlier than planned Working with early telehealth adopters, the explosion of telehealth utilization during the public health emergency (PHE) of COVID-19, and future projections of the service Coding fundamentals and nuances of telehealth, missed opportunities, and compliance issues Using telehealth to augment risk adjustment, including the requirement for “face-to-face encounter” to capture HCC diagnoses—does a computer screen count? Keisha's recommendations: One book and one song

It's often been said that the only constant in life is change. And the mid-revenue cycle is no exception. As new regulations emerge and new technologies develop, professions get radically transformed—or even erased altogether. The antidote is a commitment to lifelong learning, and embracing the discomfort that accompanies growth. That describes the mindset of Crystal May, my colleague and a Risk Adjustment Consultant for Norwood. This program was originally broadcast as a webinar interview but was just too good not to share with a broader audience. So I'm pleased to publish it on the podcast. On this show we discuss: Crystal's unique career path that began in transcription, profee coding, and ultimately risk adjustment Her current work including audits of organizational documentation and code assignments Common documentation and coding pitfalls (strokes are a major source of error—hear why) How organizations can use findings from audits to drive continuous learning and improvement MEAT criteria—examples of adequate MEAT criteria (and what happens if you're MEAT-less)? Getting comfortable with discomfort to grow your skillset and insulate yourself from industry layoffs Our joint heavy metal obsession and recommended bands

What the heck is a trauma registrar, anyway? Once upon a time even my guest asked that question. After starting a career in nursing in 1987, Stefanie Arp became a trauma nurse specialist in 2001. And quickly became tasked with the responsibilities of trauma coordinator, a position she knew very little about but found herself immersed in, whether she wanted to or not. Trauma registry opened up a new world of data abstraction, quality improvement, trauma center designation, high-pressure American College of Surgeons site surveys, and much more, including medical coding and the use of trauma activation codes. And opened Arp's eyes (and now, mine) to an under the radar profession that plays a huge impact on patient outcomes and organizational quality. We get into all of that on today's Off the Record, covering: What is a trauma registry professional and why should an organization invest in them? The nitty-gritty of the role including data abstraction process, record review and productivity expectations American College of Surgeons and facility specific requirements, including trauma center designation levels Revenue implications including the use of trauma activation HCPCS code G0930 Arp's fascinating origin story, from nurse to national consultant What makes for a good trauma registrar--desired background, skills, and mindset, and Arp's advice for folks looking to break in Finding meaning in her work (no shortage of that)

Earning your RHIA (Registered Health Information Administrator) is a huge accomplishment, and for some marks the end of a four-year academic journey and an entry into HIM. For Richelle Marting, it was only the beginning. In pursuit of her RHIA, which she eventually earned, my guest on today's episode took a class on the legal aspects of HIM. That course planted the seed for a career in law—and eventually led her to start her own law firm. All while raising two twin girls. I don't know how she managed all this, but that's why I got Richelle on Off the Record. On this show we discuss: Richelle's story from RHIA to JD. How difficult was the bar exam? Becoming an entrepreneur and starting her own law firm Most frequent type of healthcare cases: Clinical validation audits and DRG validation The coding guidelines she sees most frequently ignored or twisted to the payer's benefit, and other shady tactics What do healthcare organizations make too big a deal out of—and what are they not worried about enough? Qui Tam and the recent spate of cases initiated by organizational whistleblowers, in particular Medicare Advantage organizations Managed care contracting: Legal issues around contract negotiation, how claims get paid, timely filing, and payment policies. How quickly must plans respond to appeals, and should you put a diagnosis definition in a payer contract? What advice would she give to someone who is in HIM and considering a career in law—what does she know now that she wishes she knew then?

One of the more promising developments I've seen over my career watching the CDI profession bloom is the creation of the CDI educator role. CDI is often labeled by its critics as reactive, sending queries to the provider after he or she has already documented in the chart. This is an integral but limited part of CDI work. The main work is getting physicians to document correctly in the first place. It's the kind of work being done by Kalee Vincent, my guest on today's program. Kalee is the CDI Educator for WVU Medicine, West Virginia's largest health system and largest private employer comprised of 23 hospitals. Kalee joins me to discuss her path into healthcare, her important work and impact as an educator, and some proven strategies for teaching documentation lessons that stick with providers. Listen in as we discuss: Shifting from CDI chart reviewer to educator in January 2023—challenges and rewards, advice for those considering a similar move CDI as an RHIA: Addressing misconceptions about clinical knowledge as a non-nurse (Kalee dissected a cat in college—for real—as part of her studies) Keys to being a good physician educator: What works in a 1:1 setting vs. a medical staff meeting, how to get time with busy docs Lots of interesting examples where gaps exist and education is needed—CKD, sepsis 2.5, ASPEN, shock, heart failure and more (Kalee came PREPARED) New WVU malnutrition coalition: Why this initiative began, what the work includes, and her role on the coalition Hamming it up with ex-ACDIS directors, what downtime in the Vincent household looks like, and her Off the Record Spotify playlist selection (Taylor Swift has cracked the lineup—you knew it had to happen sooner or later)

Sepsis it seems is always in the news, never far from anyone who works in CDI or coding circles. And here we are again, back in the headlines due to its inclusion in the Office of Inspector General (OIG) Work Plan. Sepsis has been discussed so much due to the complexity of disease, the cost of treatment, complexity of coding, and increased regulatory spotlight. What else is there to say? But with it back in the spotlight I wanted to turn from the usual insular conversations in the mid-revenue cycle to someone working on the front lines of care. Amanda Hart is an ED nurse and a sepsis clinical nurse specialist at Tower Health, a regional integrated healthcare system based out of Pennsylvania. She spends a substantial amount of time battling this deadly disease, and her work has much to offer anyone who works to get it accurately documented and coded. On this episode we discuss: • Amanda's background in the military and EMS, path into nursing and eventually the ED • Her role as sepsis clinical nurse specialist and how it overlaps with CDI/coding • Pathophysiology—clinical indicators of sepsis and what makes it such a deadly disease • Problems inherent in lack of uniform definitions, what Tower Health uses, and her own take on Sepsis-2 vs. Sepsis-3 debate • The importance of early screening, including processes, technologies and people. Are EHRs and alerts helping or hindering? • Tower Health's home-grown protocol that resulted in a 32% reduction in relative mortality rate in non-POA cases. • Life on the front lines of care and how it changed Amanda as a person

If you've ever been a member of ACDIS you've almost certainly encountered Dr. Trey LaCharite'. ACDIS advisory board member? Check. Regular columnist for CDI Journal? Check. Author of the CDI Field Guide to Denial Prevention and Audit Defense? Check. Speaker at the physician advisor pre-conference every year since (at least) 2010? Yes, put a checkmark there, too. Trey is the Medical Director for CDI and Coding and Clinical Associate Professor for University of Tennessee Medical Center. He's got the holy trinity of credentials—a MD, plus CCS and CCDS (and others). On this show he brings his unique clinical and coding perspective, combined with real-world applications and trademark tell it like it is/no-nonsense perspective, in a candid interview. Note: This show was recorded prior to the 2024 ACDIS conference in Indianapolis last week, where Trey presented the session “Beyond Problem Lists: How to Document Is Just as Important as the What.” On this show we discuss: • Trey's path from hospitalist to CDI • Problem lists: How UTMCK uses them and keeps them updated • Denials and creating a “defendable narrative” using the patients' clinical story • Trey's opinion on sepsis-2 vs. sepsis-3, now back in the news due to the recent OIG Work List update • What ACTUALLY resonates with MDs, regarding the eternal question “what's in it for me”? • CDI pet peeves, proudest career accomplishment, things to do in TN, and an unexpected OTR playlist addition

Small community hospitals are the backbone of healthcare for most of the country, even today in this era of sprawling healthcare organizations and massive mergers. But while they're critical to the health of our nation, resources are often scarce, and CDI is no exception. Jennifer Cummins, BSN, CCDS, is one of just two CDI professionals covering a 222-bed not-for-profit community hospital in rural Kentucky. Advanced technology and sophisticated AI are not in her toolbox, but that doesn't mean Jennifer doesn't take pride in her work. In fact, she and her colleague are making a big impact with some old-school methods. Their CDI work helped the hospital earn the title of one of the 100 Greatest Community Hospitals in America. Proof that determination, creativity, and teamwork are still more important than tech, even in this day and age. On this show we cover: • Jennifer's origin story—ICU and ER nurse, finding her way into CDI with the help of a nursing colleague • CDI program--when it began, focus of reviews, and success metrics • Conducting chart reviews with a basic encoder, books, creativity, and the help of other departments • Logistical challenges as a small community hospital, including weekend coverage and PTO in a department of two, and rising to meet new initiatives with limited resources • Expansion to mortality reviews: Identifying the need, process, early successes, and conducting deeper, more intensive reviews • Fun things to do in Kentucky (aka., Bourbon Trail). Plus Jennifer's addition to the Off the Record Spotify playlist (Kentucky bluegrass? Find out)

I don't know about you but I'm FASCINATED with Medicare Advantage (MA). Massive growth, fueled by its shrewd marketing of added benefits beyond traditional Medicare. But also chaotic, messy, a program in need of reining in.   It's a bit of the wild west.  I like some things about MA, including its emphasis on preventative care and aligning patients outcomes with rewards. But I'm also routinely disappointed by its excesses and denial of medically necessary care.   Some days MA seems poised to overtake and end traditional Medicare. But every time I think that, another shoe drops. Intensive audits from the OIG, and sharp criticism from the likes of former CMS administrator Don Berwick. Two weeks ago we saw the nation's largest ACO get hit with a whistleblower lawsuit for alleged upcoding abuses.  To get a big picture overview and figure out where we are with the program I invited 4Sight Health's David Burda to join me on the podcast. David is 4SightHealth's news editor and columnist and hosts a podcast, the 4sighthealth roundup, covering MA and other adjacent topics.  Listen in as we discuss:  David's journalism background and eventual path into covering healthcare  MAs rapid adoption: Will it continue until Medicare is phased out—or is a reckoning coming?   The problems with MA: Gaming of risk adjustment/upcoding to make patients appear sicker, denial of medically necessary care, prior authorization nightmares, and sky-high insurer profits  What MA is doing well, should be preserved, and what needs reform  Is healthcare compatible with a free-market economy and shareholder ROI?   How David stays on top of the torrent of healthcare news, and his cool addition to the #OTR Spotify playlist     Additional reading from 4sighthealth:   What Will Happen to Traditional Medicare? https://www.4sighthealth.com/ken-terry-what-will-happen-to-traditional-medicare/   Spy vs. Spy? More Like Medicare vs. Medicare Advantage https://www.4sighthealth.com/spy-vs-spy-more-like-medicare-vs-medicare-advantage/   

Listeners of Off the Record may recall our episodes on the OIG audit of severe malnutrition directed at North Carolina based Vidant, now ECU Health. Vidant/ECU won a landmark case against the OIG in large part because it had a multidisciplinary clinical and coding team in place to ensure that severe and other forms of malnutrition were appropriately documented in the record and captured. That effort was spearheaded by CDI and coding experts, but also by a great clinical team including my guest today. Ashley Strickland is the adult clinical dietitian supervisor and an surgical/trauma intensive care dietitian at ECU Health. Her primary focus is critical care, complex GI patients, and nutrition support. She's also an independent contractor and educator for the Academy of Nutrition and Dietetics and sits on the American Society for Parenteral and Enteral Nutrition's Reimbursement Malnutrition Task Force. On this show we cover: • What is a hospital based registered dietitian (RD), and Ashley's life-saving clinical work supporting critical care/trauma/surgical intensive care patients • How her work impacts documentation/coding/diagnosis of malnutrition and obesity • Strategies for appropriate capture of severe and other forms of malnutrition • The OIG case from Ashley's perspective, including prepping with mountains of paper records in the war room, courtroom experiences, and lessons learned • Advice for professionals dealing with egregious denials, including flimsy justifications of “not enough care” directed at a condition, or denying conditions clearly reportable per Official Guidelines for Coding and Reporting • Definitions and controversies: AND/ASPEN criteria vs. the Global Leadership Initiative on Malnutrition (GLIM), and compliance concerns with the emergence of “mild” malnutrition • My Dave Matthews gaffe (sorry, heavy metal guy here)

In 2009 ACDIS was growing. The association's boot camps were taking off. We were at the point where we needed to hire our first full-time instructor and CDI educator. That person was Lynne Spryszak. Lynne had been in CDI since 2002 and volunteered as an inaugural ACDIS inaugural advisory board member in 2007. She married experience (rare in what was then a new profession) with passion and a desire to educate. It was a perfect fit. Lynne worked with me for a couple great years and then moved on. But I've continued to follow her career from afar—a career that has recently come to a well-deserved retirement. Well, sort of (she's currently looking for some supplemental part time work). Lynne is definitely one of CDI's “OGs” and on this show we recap her career, wisdom, and the true purpose of CDI. We cover: • Working full-time in a grocery store, late start in healthcare, early 90s nursing days in a medical-oncology unit, and transition into CDI • Most memorable stops of her career including ACDIS, working as a consultant, performing GEM mappings for the transition from ICD-9 to ICD-10 • Taking over the CDI boot camp line and transforming it into her own (while working alongside annoying colleagues like myself) • Surviving a bout with bladder cancer—dark days of diagnosis, aggressive treatment, and cancer free since 2016 • Biggest changes in CDI from 2002 to today—is Lynne optimistic or pessimistic for its future? • The meaning she derived from CDI work and thoughts on its true purpose: An important part of the chain of patient care • Retirement plans, grandchildren, part-time work, and her Off the Record Spotify playlist selection

If you're an aspiring medical coding professional and on LinkedIn, you might know my guest today. In fact, you probably do. She's positively burst onto the scene. Not necessarily as a content expert dropping coding or clinical expertise (although that's coming, to be sure), but someone who has documented her journey to medical coding in remarkable detail and honesty. From entrepreneurial web developer, metalsmith, piano instructor, and used book seller, to medical coder and LinkedIn motivator, and now to Off the Record (perhaps her greatest achievement to date), I am joined by the very unique Revka Stearns. By the way, the piano intro and outro you hear on this episode? That's hers. On this show we cover: • How and why the (seemingly) sudden change of direction into medical coding after a life of entrepreneurial pursuits • Obtaining her CCS and CPC-A: Studying, exam day, and the Andrews School of Medical Coding • A whale of a job search that ultimately landed Revka at Hospital Sisters Health System, and her motivating advice for future job seekers • Documenting her journey on LinkedIn, and feedback she's received from readers • First month on the job as a new code: Training, tools, and the most challenging and rewarding aspects of the job • Present and future plans • What Revka does in her “spare time,” and some emotional top hit(s) for the OTR Spotify playlist

Having worked in and around medical coding and CDI for almost 20 years, I can say for certain that few topics vex coders and CDI professionals more than the dreaded recertification process. Credential maintenance. CEUs. CEU fees. Conference CEU codes. Certificates. On and on. It's a cottage industry unto itself. It can be frustrating and confusing, and if you're not on top of it, costly. In my ACDIS days we had folks lapse, despite our generous grace periods. They still do. Few things get folks more fired up than this. So, I wanted to get someone on the podcast who both understands the process deeply, and dedicated a portion of his career to making it easier. Who better than the (self-described) Medical Coding Geek himself, Brian Cui? Brian is the founder and owner of Medical Coding Geek, a platform that promotes and supports the medical coding, HIM, and CDI community. He creates and hosts educational and engaging content, including the Not Elsewhere Classified podcast, the Medical Coding Geek YouTube channel, and several Facebook groups. On this show we cover: • Brian's background and path into medical coding, CDI, and current role as an auditor for Cotiviti • What he finds most challenging about recertification • What newly credentialed folks get wrong about recertification and credential maintenance • Important recent changes to recert requirements, including the recent controversial AHIMA proposal to require more CEUs come from national • Free resources many people overlook, including his own CEU HIT list • Advice on getting financial support from your employer • Being a good coder/CDI professional, work-life balance, and growing your career Enjoy!

The turn to a new year is the time to set new goals. And who better to set them with than a person who has achieved a career far beyond many of us ordinary mortals—but has the honesty and humility to reveal where she falls short. Dr. Nicole Fox is Associate Chief Medical Officer, Associate Professor of Surgery, Medical Director of pediatric trauma, and Medical Director of CDI for Cooper University Hospital, a level 1 trauma facility in Camden, NJ. She made for a great guest to kick off season 3 of Off the Record. This was one of my favorite interviews to date, very personal and revealing for the both of us. I keep trying to get Nicole to start her own podcast and if you listen you'll understand why. On the show we discuss: • Nicole's biggest accomplishments of 2023 and progress on the path of Ikigai (a Japanese concept related to finding purpose and reason for being) • Nicole (and my own) process for annual review and goal-setting, both personal and organizational • Striking the balance: Developing goals that challenging and therefore worthwhile, but also reachable/achievable. • Cooper Health's Q1 2024 CDI goal: In-depth department audit, aligning people with interests and strengths. You'll want to hear this. • Making goals “sticky” so they don't fall off Feb. 1 • Failures, getting “smacked upside the head” at age 40 and moving from personal accomplishments to mentoring and growing others as we age • Other tidbits from her interesting life, including the first OTR Spotify playlist entry of 2024 (Willie Nelson makes a first and long-overdue appearance).

The end of the year is a time to reflect, to look back on what we've accomplished and learned.   And enjoy the time away from the office and have some fun.   On today's show I'm joined by couple of guests and friends from my home base at Norwood for remembrance, lessons learned, and some meaningful personal and professional successes. We also talk about the major themes that emerged over a year of podcasting.  Sandra Love, Director of Solutions, and Joanne Wilson, Senior director of Solutions, join me on the final episode of 2023 to discuss:  End of year reflections, including my own (thorough) process for annual review  Personal and professional accomplishments: Sandra and Joanne discover work-life balance  What does the Mid-Revenue Cycle professional of the future look like? What must they bring to the table to succeed?  Value-based care, capitated payment models and HCCs: Will they replace fee for service and DRGs? Will Medicare Advantage (which has this surpassed Medicare in covered lives) replace Medicare entirely? What skills do we need to work in both?  The state of CDI and coding technology and how mid-revenue cycle professionals should work (healthily) alongside it   Holiday and New Year's plans  In closing, the world is more than ever full of noise, endless content streams, endless voices competing for our time, eyeballs and ears. I hope Off the Record has provided something more.  Thank you for taking this journey with me. I look forward to bringing you more thought-provoking discussions with great guests in 2024.   Merry Christmas and Happy Holidays! 

Generative AI in healthcare is … truly wild. A technology in bloom with little to no regulations, with all the messiness and breathless optimism that entails. The accuracy of these products including ChatGPT are a work in progress. As this podcast debuts ChatGPT outperformed humans on a mock version of the American Board of Psychiatry and Neurology (ABPN) boards, but in another study nearly 75% of its answers to drug-related questions were incomplete or wrong, including some outright hallucinations. But like it or not this technology is here on our doorstep. A Dec. 6 KLAS report said that 58% of healthcare executives said their organization will implement or acquire a generative AI solution in 2024. In fact, if you're a CDI or coding professional, you may already be coding from an AI generated history and physical, or progress note. Also, the headline for this show was written by… ChatGPT. I wrote the rest. Joining me to discuss the topic is Dr. Harvey Castro. Dr. Castro is a serial entrepreneur, a physician who in the course of his work taking care of patients quickly saw the power of AI and decided to go all in. His Linkedin profile lists him as a “ChatGPT Healthcare Advisor.” He's the CEO of Medical Intelligence Ops, an assistant professor at the University of Texas at San Antonio, an author, and a national speaker, including a keynote at this week's HIMSS conference “AI in Healthcare Forum.” Listen in as we discuss: • A self-indulgent turn into podcasting software (Castro's setup is far better than mine) • Why is my cup half empty and Castro's overflowing with optimism—what makes him so damned positive about generative AI? • Emerging AI powered healthcare technologies that excite Castro, and you should probably know about • Applications in the coding/billing/mid-revenue cycle space • A plunge into the deep end, and beyond—Elon Musk conspiracy theories and The Singularity • How a CDI and coding professional could use these tools today, and in the future • Existential threats posed to work

Technology. I'm of a mixed mind. Broadly, I think technology is a blessing for humanity. It saves lives. In my small corner of the world I interview guests from across the nation over Zoom, and deliver the final product via the magic of podcast. That may or may not be a blessing depending on your opinion of Off the Record. But it goes to show you its reach and impact. But it also strikes me as naive to paint technology as a universal good. Does anyone think smartphones and social media wars have unambiguously improved the country, or how we communicate as a species? How about ransomware and AI hallucinations? One thing that is true: Love it or hate it, technology is here to stay. And is increasingly ubiquitous, ever more powerful, and something we cannot work without. I wanted to talk to someone whose organization is a heavy tech user. Not a vendor representative, but a customer. To get a more objective look at some of the tech we're using in CDI and coding. Joining me for this episode is Kory Anderson, Medical Director of Physician Advisor Services, CDI, & Quality, and Enterprise Medical Staff President at Salt Lake City, Utah based Intermountain Health. It's an organization I consider very tech forward. On this show we cover: His role at Intermountain, a “day in the life” of Kory Anderson Intermountain's CDI/coding tech stack, with a focus on computer assisted physician documentation (CAPD). Impact on MD practice and CDI metrics and out of the box use cases. How smart is current tech? Does it weaken critical thinking, or will it replace CDI and coding professionals?  The drawbacks/limitations that vendors don't tell you about. What can't it do, and where it still falls short. Intermountain's ongoing merger with SCL Health, a big obstacle of which includes a migration from Cerner to EPIC A cool new addition to the OTR Spotify playlist

Off the Record recently featured a wide-ranging conversation with Vaughn Matacale, physician advisor for Vidant Health (now ECU Health), an organization that found itself on the receiving end of an OIG audit of severe malnutrition claims. On this episode I'm pleased to bring you a continuation of that story from the legal team that helped the organization win the case and strike a blow for clinical truth. It's not every day you get to hear a lawyer's perspective on coding and documentation. But this episode is a double-dose, featuring Anderson Shackelford and Susan Hackney with North Carolina-based K&L Gates LLP. On this show we cover: • Vidant case details, and fighting an uphill battle against a formidable foe • Weaknesses exposed in the OIG's independent audit team and lack of consistent clinical review criteria • Broad takeaways from the case, including best practices for making your organization a harder target • Other legal liabilities related to documentation and coding you might not be aware of • Open discussion: Should CDI programs be worried about being “better” than their peers at capturing certain diagnoses? Link to OIG audit report “Vidant Medical Center Incorrectly Billed Medicare Inpatient Claims with Severe Malnutrition”: https://oig.hhs.gov/oas/reports/region3/31500011.asp

As a non-clinician I can think of few things more terrifying than having responsibility for the life of a fragile newborn in your hands, and your hands alone. Welcome to the early nursing career of Sandra Love. Sandra served a labor and delivery nurse in rural North Carolina and survived some harrowing experiences that continue to inform her work today as Director of Solutions for Norwood. Sandra learned that infants are not just small adults—they have their own unique clinical profiles. That same axiom holds true for documentation and coding, too, which is often why pediatric CDI programs fail. But there are some very real opportunities that you're leaving on the table without a pediatric focus. We talk about all of that on this episode Off the Record. If you have a pediatric CDI program or are thinking expanding into one, this is a show you'll want to listen to. Topics include: • Sandra's early experiences working in a level 2 nursery with specialty support a long way away • Transition into adult medicine and eventually CDI at Wake Forest • Why most hospitals are off the mark with pediatric CDI • Documentation clarification opportunities in the pediatric space • Suggestions for engaging pediatric providers and obtaining buy-in • And of course, the latest addition to the Off the Record Spotify playlist

It's often said that to be a good CDI or coding professional you have to roll up your sleeves and get clinical. If you code just what is explicitly documented you will miss opportunities; if you don't understand A&P and pathophysiology, you will make mistakes. But what about those who take the opposite path? Katie McLaughlin became a registered nurse at age 23, then went back to school to earn her doctorates before becoming a nurse practitioner in 2007. Today—at least until very recently, when her organization opted to discontinue accepting Medicare Advantage patients and shuttered its risk adjustment program—she became Population Health Clinical Advisor: Clinical Documentation Integrity, Risk Adjustment, and Epic Informatics, for Scripps Health. A clinical path, to coding and CDI. Today she is looking for the next opportunity. But given her clinical foundation, coding expertise, EHR savvy, and above all, passion and vision, she will be landing very well, and very shortly. Katie joined me for this week's episode of Off the Record, where we discuss: • Her path into nursing, clinical medicine, and ultimately risk adjustment • Prospective chart reviews—a 2 a.m. vision, and implementation • Leveraging Medicare annual wellness visits • Scaling risk capture by customizing EPIC • Building dedicated Internal Wellness Clinics focused on screening and risk capture • Unexpected free time and plans for her next career move

Severe malnutrition is a major predictor of mortality/morbidity. In a five-year observational study cited by the National Institutes of Health, malnourished patients showed an eight times greater risk of harmful falls during hospitalization as compared to well-nourished patients. Further, malnutrition is associated with increased risk for septic shock, acute kidney injury, stroke, and intubation. So it's important to get severe malnutrition documented and coded. Unfortunately, doing so thoroughly and systematically can also make you an audit target. Vidant Health—now part of ECU Health—found that out the hard way in January 2017, when it was the target of a high-profile audit by the Office of Inspector General (OIG). The report was scathing and seemed to indicate that Vidant had major problems reporting the condition. What the OIG didn't know was that Vidant had Dr. Vaughn Matacale. Vidant fought back. And ultimately prevailed. It was not just a major win for the hospital, but for clinical integrity and autonomy of hospitals nationwide. We talk all about this landmark case on this episode of Off the Record. And get caught up on what's new with Vaughn, including his well-stocked beer cellar and a rock band recommendation for the OTR Spotify playlist I've never heard of before. How is that possible? Tune in and listen as we cover: • The initial OIG records request and onsite visit • Reading the initial painful audit report with its 89% error rate: https://oig.hhs.gov/oas/reports/region3/31500011.pdf • Fighting back: An extraordinary response letter and building a case • Courtroom culmination (and celebration) • Advice for other hospitals: Shoring up severe malnutrition claims from audit and denial • Some broad discussion on the OIG and its work • Fun stuff including beer and music

Stop hating on hospitals. It's a sentiment most Off the Record podcast listeners would probably agree with. But not everyone. Hospitals are under assault in some corners, including the media and in the halls of government. We need a villain and hospitals often find themselves playing the role of fall guy. For example, many blame them for out-of-control healthcare costs, citing a lack of cost transparency and exorbitant charging practices. Jugna Shah, MPH, founder and president of Nimitt Consulting, Inc. pushes back on these assertions, making a compelling case that a broken system is to blame. Hospitals own a piece of the problem, but by and large are doing their best to navigate inadequate and complex rules and opaque payer requirements. Many of the gotcha soundbites on Twitter, especially ones that place full blame on hospitals, are misguided, she says. On this show we cover: • Jugna's unique path into healthcare and hospital advocacy • Pricing transparency: The problem with posting prices, and the real reason why outrageous hospital charges exist • Why and how hospitals must charge to get adequately reimbursed for CAR-T and other expensive therapies, drugs, and services • Site neutral payments. Why should hospitals be paid multiples of the same procedure done at an ASC down the street? There are reasons… • Fighting back against payer denials of packaged/bundled services • Best practices for commenting to CMS and making your voice heard

During my last conference as ACDIS Director in Oct. 2021 I had the pleasure of introducing Dr. Nicole Fox as our opening keynote. Nicole is not a professional lecturer but delivered one of the most impactful and inspiring speeches I've seen, covering her work as a pediatric trauma surgeon and her challenges as a single mother raising four children. Understatement: Nicole is an impressive human being. In addition to a heavy clinical rotation, she's the Associate Chief Medical Officer, Associate Professor of Surgery, and the Medical Director of pediatric trauma for Cooper University Hospital, a level 1 trauma facility in Camden, NJ. Oh, and she also serves as Medical Director for the hospital's CDI program. Nicole is recently back from a World Trauma Congress in Tokyo and was married this year. We get caught up on all of this on this episode of Off the Record. We cover: • Advances in trauma treatment and insights into Japanese culture and the philosophy of Ikigai • A “typical” day in pediatric trauma—instructive for any CDI professionals who might be grumbling why queries aren't always answered timely • Nicole's inauspicious path to CDI (she was one of the worst documenting physicians in her organization, with a number of outstanding charts so large you have to listen to believe) and unlikely path to medical director of CDI • Vendor shortcomings—overpromise and under-delivery • Mortality reviews—getting started, common clarification opportunities, and the delicate dance of querying a physician to provide further detail on an expired patient • Recent domestic changes • Her favorite song for the OTR Spotify playlist, and our personal encounters with Steven Tyler of Aerosmith (hers is much, much cooler than mine) Books mentioned on the show include: • Ikigai: The Japanese Secret to a Long and Happy Life, Hector Garcia and Francesc Miralles • Ichigo Ichie (same authors) • Wabi Sabi, Beth Kempton Enjoy! #OTR

It's not easy moving into Clinical Documentation Integrity as a new nurse or coding professional. But now imagine what it's like if you're from Maryland. And it's 2006. These were pre-ACDIS days, in a state which used APR-DRGs. In other words, no best practice, little information, and no real community. But Dawn Diven, Enterprise System Director of Clinical Documentation Improvement for WVU Medicine, is used to taking on difficult challenges—and overcoming them. And she's got a track record to prove it. Which you'd never know because she's also humble and down to earth as they come. On this episode we discuss: How one survived (and thrived!) in CDI in the stone age that was 2006, in Maryland of all places. Hint: Networking is key. Dawn's career progression and leap into leadership in 2016 The lay of the land at an ever-changing WVU program: Implementing assistive software (a two-year process from approval to adoption!) and a CDI career latter The struggles of being an early adopter of outpatient CDI How to build a business case: Where to start, how to do it, and Dawn's secret sauce for 100% success rate, to date A revealing look at some of her struggles and failures The difficult reality and compromises inherent in leading a team A classic rock hit that I can't believe didn't make the OTR Spotify playlist ... until now.

Most people envision and expect careers to follow a straight line, gently upwards and to the right, in one direction. Once you've found the type of work you want to do you get promoted as high as fortune and talents will take you, until the day you retire. Kim Higgins is an exception to this rule. A year ago Kim was serving as the interim CDI director for AdventHealth West Florida Division, a massive health system (West Florida has 13 hospitals alone). Her responsibilities included day-to-day management but also helping build a case for new staff, demonstrating ROI, and growing the department. That was in 2022, not so very long ago. Today you'll find her working as a remote CDI specialist reviewer for Valley Medical Center, a small, standalone acute care hospital located in Washington State. And she couldn't be happier, because it was the right move for her. We get into the reasons why and much more on this episode of Off the Record. On this show we cover: Her motivations and reasons for leaving leadership A day in the life of a remote CDI professional Impacts on her personal and professional life, pro and con West coast vs. Southeast chart reviews—there is a difference Kim's non-traditional career path into CDI (Cub Cadet?) Discovering what really matters in work, and life

To be an effective leader you have to have a vision and be willing to implement changes that disrupt the status quo. But you also have to involve your team, and use diplomacy to obtain buy-in. In short, be a team player with a little bit of swagger. It's a delicate dance, but it describes the tightrope Sheri Blanchard, Senior Director of Clinical Documentation Excellence and Revenue Management, had to walk. And she did so skillfully. After taking over the Clinical Documentation Excellence program at Orlando Health in 2018 as a new leader Blanchard put her own unique stamp on the program--all the while recognizing her team is everything, and involving them at each step. On this show we cover: • The Clinical Documentation Excellence (CDE) program at Orlando Health. • Arriving at the organization as a new face in 2018, seeking to make change • A day in the life of a busy senior CDI director covering 11 facilities • Orlando Health's unique DRG reconciliation process, which includes a dedicated resource and final assignment authority given to CDI • Out of the box CDI work including monitoring long LOS patients and patients that flip to observation • Advice for new CDI leaders • The most metal entries on the OTR playlist to date (Sheri likes AC/DC, GNR, etc., which automatically makes her cool in my book)

Few CDI professionals are rising as fast as Faisal Hussain, Executive Director of CDI at Wellstar Health System in Georgia. Fewer still have come as far as he has, both literally and figuratively. A foreign medical graduate and native of Pakistan, Hussain has risen up through the ranks in a remarkable career in healthcare. In his current role he is responsible for overseeing the CDI strategy and operations for the entire Wellstar health system, comprised of nine hospitals and more than 300 medical offices, as well as cancer centers, rehabilitation centers, hospice facilities, and urgent care locations. It's a huge task and he recently completed a firehose of a first year with the organization. But in case that didn't keep him busy enough, Hussain this year also ran for and was elected to the ACDIS advisory board, in addition to serving as a member of the ACDIS leadership council and the ACDIS regulatory committee. And he's done it all with kindness and humility while raising a young family. On this show we cover: • A day in the life of Faisal Hussain, Executive Director of CDI • WellStar's CDI strategy and metrics for success, including a focus on chart touches that matter and a proactive rather than reactive approach to chart review • Recent wins (build and pilot of a promising homegrown EHR documentation tool) and struggles as a new leader and new(ish) dad seeking better work-life balance • An unlikely and winding path from graduate of Aga Khan University in Karachi, Pakistan, to MD, and finally to CDI • Winning the organizational Diversity in CDI award at the 2023 ACDIS conference, and his own prior experience with discrimination • His favorite classic pop or rock song (because, it's Off the Record, duh). I refused to bend on “Baby Shark.”

News flash: Many (most?) physicians aren't on board with CDI initiatives and coding practice. It's understandable; they're busy with patient care, and in their remaining hours are swamped with chart completion. Answering clinical queries and documenting with greater specificity is either seen as a chore or falls by the wayside entirely. Sometimes it takes real-world impact to make the lightbulb go off and touch a match to tinder. Tom Brazelton, MD is a practicing pediatrician and the CDI medical director for UW Health in Madison, Wisconsin. His passion for CDI was ignited by seeing how documentation and coded data was reflecting on organizational quality (and not in a good way). So, he decided to get involved. Brazelton helped a fledgling program comprised of four CDI professionals grow to more than 35 FTE across four hospitals, all while achieving a 98% physician response rate. His story of how achieving buy-in looked in a long-ago orthopedic surgery meeting is worth listening to alone. Today CDI is in his blood. Brazelton was recently given an organizational award, “Superheroes in Scrubs,” for his efforts, and he now makes the ACDIS conference a regular stop. On this program we cover: Dr. Brazelton's journey into clinical medicine, a day in the life of a PICU physician, and his path into CDI The UW CDI/coding program today, including staffing and metrics, successes, and ongoing challenges A counter-narrative to the belief documentation leads to provider burnout A compelling vision for the CDI professionals of tomorrow And of course, his top classic rock hit

There comes a point in our life when we all need to take an adventure. For most that means a vacation to an exotic faraway continent. For others, that might mean taking a new job, or changing careers altogether. Or starting a family. All of these are adventures of one sort or another. All are wonderful. But then there is Howard Rodenberg. Howard decided at age 60 to take a real-life adventure. To the South Pole, where today he is serving as a physician at the Amundsen-Scott South Pole Station with the U.S. Antarctic Program. Prior to this monumental decision Howard served as a physician advisor to the CDI program at Baptist Health in Jacksonville, FL, and chaired the ACDIS regulatory committee. And took adventures of the mind playing the fantasy role playing game Dungeons and Dragons. All of which immediately endeared me to him and led to this interview. On this episode (conducted tenuously via satellite link) we cover: • Why do this? What did your family think? • What does an average day look like? Have you had any medical emergencies? • Do you spend much time outside? Can you? • What's the hardest part about life in the South Pole and what don't most people understand about the conditions and isolation? • Do you have to document and code your work? • What have you learned about yourself? • What's the first thing you're planning to do upon your return? While there is not as much CDI, coding, and health records management talk as you'd find on an ordinary episode of OTR (although we do get into this, and CDI may be part of Howard's future plans), I guarantee you'll be inspired by his story. And possibly find the courage to take an adventure of your own. Even if it doesn't lead to the South Pole.

After a short break that was not really a break because we were on the road at ACDIS 2023 we're back with another episode of Off the Record.  Today I'm joined by fellow conference-goer, presenter, and colleague Jason Jobes, senior vice president of solutions at Norwood.  On this show we dive into the recently concluded ACDIS 2023 national conference in Chicago, which was my 15th (yes, I've been to every single one from 2008-present, not including the virtual event of 2020, and I think I'm the only person on the planet who can say this) and Jason's first. We had a blast, learned a lot, and came back recharged and optimistic for the future of the CDI profession. I also had the honor of remembering my colleague Melissa Varnavas with a Day 1 keynote.  We then switch gears to outpatient CDI and the ongoing transition to value-based reimbursement with a focus on Jason's session from the ACDIS Outpatient Symposium, entitled The Importance of Risk Adjustment in Value Based Settings.   We cover the following topics:  Payer relationships, and how CDI and coding leaders and their respective organizations should approach payers with whom they have had (and likely still have) an adversarial relationship, but now find themselves in a shared savings agreement that rewards cooperation.  The importance of patient scheduling, including leveraging your case managers, social workers, and population health team to get patients in to be seen. Both to manage their health in less expensive settings but also to capture risk. Annual Wellness Visits can play a large role here.  What if you don't have an OP CDI program? How to figure out where your opportunities lie and where to start. Hint: It's about understanding and seeing your patients, knowing what risk program they are in and what clinical conditions they have, and seeing them at least annually. And monitoring process and outcome metrics to ensure that patient complexity is fully captured.  The Medicare Advantage 2024 Advance Notice final rule and the anticipated impact of the transition from V24 to V28 of CMS-HCCs over three years (2024-2026).  The current landscape of intense regulatory scrutiny, and the corresponding shift from revenue maximization/capture to compliance and revenue protection. We discuss Jason's recent series on LinkedIn analyzing the seemingly endless stream of OIG audits of Medicare Advantage payers on presumed overcoding, including ongoing patterns of (likely) error.  And of course, we discuss Jason's top 90s rock/pop hit. He's a little younger than me so I let him get into the music of his youth, rather than mine—the 80s. Against my better judgement. 

CDI and coding professionals typically recoil from the dreaded word, “payer.” After all, provider-payer relationships are often adversarial at best, hostile at worst. Clarify the diagnosis or procedure with the physician, apply the medical code … only to have the payer downcode or outright deny the claim.  My guest on today's podcast understands the frustration because she once worked in the hospital setting. Today she works on the payer side. But here's where things get interesting.  New hospital-insurance plan arrangements, often in the context of Medicare Advantage contracts, require partnership rather than combat. And if all goes well, the beneficiary is the patient.  At least, that is the belief of Colleen Gianatasio. Colleen is the Director of CDI and Coding for Capital District Physician's Health Plan. On the show we discuss:  The changing landscape of healthcare reimbursement, from fee-for-service to capitated, pay-for-performance models The intersection of coding and CDI with quality, and how the work of CDI professionals can improve star ratings Today's highly charged regulatory environment of OIG Medicare Advantage audits and CMS enforcement: How did we get here, and digging out for a better tomorrow Common compliance vulnerabilities from the perspective of a payer Provider education strategies