Sepsis Blog Series: Part 1

CMS’s new sepsis readmission measure marks a significant shift in how organizations must approach documentation integrity, coding, quality measurement, and clinical validation. Built on administrative claims data and risk adjustment, the measure evaluates hospital performance using publicly reportable 30-day readmission outcomes following sepsis hospitalization. ​​(CMS)​

This sepsis series is designed to help organizations build the capabilities necessary to ensure clinically supported conditions are accurately represented from provider documentation through final coded data and ultimately reflected in quality outcomes and public reporting. ​​(CMS)

​

Week 1: From DRG Optimization to Outcome Optimization

Focus: Why the finalized CMS Sepsis Readmission Measure changes CDI’s role.

Key Tenets

• CDI is evolving beyond MS-DRG optimization and reimbursement integrity.
• Documentation now directly influences quality reporting and readmission performance.
• The measure evaluates hospitals on unplanned 30-day all-cause readmissions following sepsis hospitalization.
• Accurate representation of patient complexity supports fair hospital comparisons. ​​(CMS)​

Executive Indicators to Monitor

As organizations shift from documentation optimization to outcome optimization, leaders need visibility into the measures that signal whether patient complexity is being accurately represented and whether improvement efforts are translating into measurable performance outcomes. The following indicators can serve as an initial executive dashboard:

Outcome Measures

• Sepsis readmission rate
• Risk-standardized readmission rate (RSRR), once available

Documentation and Coding Measures

• Severe sepsis capture rate
• Septic shock capture rate
• Frailty capture rate
• Documentation-to-code match rate
• Risk-adjustment completeness

Clinical Validation and Denials Measures

• Clinical validation denial rate
• Appeal overturn rate

Together, these measures provide insight into the entire continuum of documentation integrity, coding accuracy, clinical validation, risk adjustment, and outcome performance. Monitoring them at the executive level reinforces the understanding that documentation is not solely a revenue cycle function but a critical component of quality measurement and public reporting. ​(CMS)

Action Item: 

Conduct an executive briefing with CDI, Coding, Quality, Revenue Cycle, and Physician Advisor leadership to review the finalized Sepsis Readmission Measure and identify where accountability currently exists for documentation, coding, clinical validation, readmissions, and quality reporting. ​(CMS)

Leadership Reflection

If CMS assessed our organization’s ability to accurately represent patient complexity today, would we have confidence that documentation, coding, quality, and clinical validation efforts are working toward a common outcome, or are they still operating as separate initiatives? ​(CMS)

Week 2: Documentation Is Not the Finish Line

Focus: Understanding why documentation alone does not impact quality measures.

As organizations prepare for implementation, leaders should address a common misconception: documentation improvement and coding are not separate strategies. They are consecutive steps in the same process for accurately representing patient complexity in claims data. The sepsis readmission measure is built on administrative claims data. Providers document the clinical story, but only documented conditions that are appropriately translated into coded data can influence risk adjustment, quality reporting, and hospital performance measurement. ​​(CMS)​

Key Tenets

• The measure is calculated from administrative claims data.
• Providers document the clinical story, but CMS measures what is reflected in coded data.
• Conditions that are documented but not coded cannot influence risk adjustment.
• Documentation and coding are consecutive steps in the same outcome-measurement process. ​​(CMS)​

Executive Indicators to Monitor

• Documentation-to-code match rate
• Query response rate
• Query agreement rate
• Diagnosis specificity rate

Action Item: 

Select a sample of recent sepsis discharges and compare documented diagnoses against final coded claims to identify conditions that were documented but not coded, coded but poorly supported, or insufficiently specified. Use findings to establish a baseline documentation-to-code accuracy rate.

Leadership Reflection

How often do we assume that a documented diagnosis automatically influences quality performance, risk adjustment, and public reporting without verifying that it was ultimately translated into coded data?​(CMS)

Week 3: Closing the Documentation-to-Code Gap

Focus: Strengthening the CDI-Coding partnership.

Key Tenets

• CDI and Coding should not function as independent quality strategies.
• Quality measures require both documentation integrity and coding integrity.
• Documentation-to-code reconciliation should extend beyond DRGs to quality outcomes.
• Missing translation from documentation to codes can affect reimbursement, risk adjustment, public reporting, and measure performance. ​(CMS)​

Executive Indicators to Monitor

• CDI/Coding reconciliation findings
• Coding accuracy rate
• Severe sepsis coding consistency
• Septic shock coding consistency
• Missed risk-adjustment diagnoses

Action Item

Establish a recurring CDI-Coding reconciliation review focused on quality-impacting diagnoses such as severe sepsis, septic shock, malnutrition, frailty, respiratory failure, acute kidney injury, and other major risk-adjustment variables. ​(CMS)​

Leadership Reflection

If CDI and Coding reported to different departments tomorrow, would we still be confident that risk-adjustment diagnoses are consistently represented in claims data?

Week 4: Documentation Becomes a Quality Strategy

Focus: Connecting documentation and coding to risk adjustment and public reporting.

Key Tenets

The sepsis measure risk-adjusts for conditions including:

• Severe sepsis
• Septic shock
• Organ dysfunction
• Chronic conditions
• Immunocompromised status
• Frailty
• Prior healthcare conditions
• Demographic characteristics

These conditions only influence risk adjustment when appropriately documented and coded. ​​(CMS)​

Executive Indicators to Monitor

• Risk-adjustment completeness
• Organ dysfunction capture rate
• Chronic condition capture rate
• Quality measure performance

Action Item

Perform a risk-adjustment gap analysis using sepsis cases to determine whether diagnoses included in the CMS methodology are consistently documented and coded across physicians, service lines, and facilities. ​​(CMS)​

Leadership Reflection

If a patient with significant complexity experiences a readmission, can we confidently say that the risk-adjustment model had access to a complete and accurate representation of that patient’s severity, comorbidities, organ dysfunction, and frailty? ​(CMS)

​

Week 5: Physician Advisors and the Sepsis Champion

Focus: Building physician leadership around documentation integrity and outcome optimization.

Key Tenets

Physician Advisors can support:

• Sepsis clinical validation
• Documentation improvement
• Physician education
• Readmission reviews
• Quality performance initiatives

A Sepsis Physician Champion can help:

• Drive provider engagement
• Review readmission trends
• Identify practice variation
• Promote evidence-based care
• Support documentation consistency

Sustainable success requires physician-led alignment between clinical care, documentation, coding, and quality measurement. ​(CMS)​

Executive Indicators to Monitor

• Physician education participation
• Provider documentation scores
• Sepsis query trends
• Physician advisor interventions
• Physician champion engagement

Action Item

Identify a Physician Advisor and/or Sepsis Physician Champion to partner with CDI, Coding, and Quality in provider education, readmission review, clinical validation discussions, and documentation performance monitoring.

Leadership Reflection

Who in our organization is accountable for influencing physician documentation behaviors, educating providers on evolving quality measures, and creating alignment between clinical practice, documentation, coding, and quality outcomes? ​​(CMS)

​

Week 6: Frailty- The Next CDI Frontier

Focus: Improving representation of patient complexity through frailty capture.

Key Tenets

The finalized methodology includes a Multiple Chronic Conditions Frailty Index that incorporates indicators such as:

• Disability
• Debility
• Functional decline
• Malnutrition
• Durable medical equipment dependence

Frailty documentation often requires collaboration among:

• Hospitalists
• Geriatrics
• Rehabilitation Services
• Palliative Care
• Nursing
• Care Management

Frailty may become one of the most important drivers of risk-adjusted complexity under outcome-based measurement. ​​(CMS)​

Executive Indicators to Monitor

• Frailty capture rate
• Malnutrition capture rate
• Functional decline documentation
• Debility documentation
• Palliative care involvement

Action Item

Partner with Rehabilitation Services, Nursing, Care Management, Geriatrics, and Palliative Care to identify opportunities to improve recognition and documentation of frailty, debility, malnutrition, functional decline, and durable medical equipment dependence. ​(CMS)​

Leadership Reflection

Would an external reviewer examining our records consistently recognize the patient’s functional decline, frailty, malnutrition, and overall complexity, or are we still under-representing these important risk factors in the health record? ​(CMS)

​

Week 7: Denials as Clinical Intelligence

Focus: Using denials and appeals to improve documentation and quality performance.

Key Tenets

Medicare Advantage payers frequently challenge sepsis diagnoses using:

• Sepsis-3 definitions
• Proprietary clinical criteria
• Retrospective clinical validation reviews

Rebuttal letters often contain:

• Organ dysfunction analyses
• Severity-of-illness discussions
• Clinical support for sepsis
• Documentation vulnerabilities

Rather than treating denials solely as revenue-recovery activities, organizations can use them as tools for education, validation improvement, and documentation enhancement. ​(CMS)​

Executive Indicators to Monitor

• Clinical validation denial rate
• Sepsis denial rate
• Appeal overturn rate
• Denial categories by provider
• Denial categories by service line

Action Item

Review the previous six months of sepsis clinical validation denials and categorize common themes such as organ dysfunction documentation, Sepsis-2 versus Sepsis-3 disagreements, severity representation, and physician documentation opportunities

Leadership Reflection

What are our top five sepsis denial themes, and how often are those same themes appearing in readmitted sepsis patients?

Week 8: From Clinical Validation to Quality Measurement

Focus: Connecting clinical validation and quality measurement.

Key Tenets

Two questions increasingly overlap:

Clinical Validation

Was sepsis clinically supported?

Quality Measurement

Was the patient’s complexity accurately represented?

Organizations that address both questions together create stronger alignment among CDI, Coding, Physician Advisors, Quality, and Denials Management teams. ​​(CMS)​

Executive Indicators to Monitor

• Denial-to-readmission overlap
• Readmissions among denied sepsis cases
• Clinical validation trends
• Risk-adjustment vulnerabilities identified

Action Item

Bring CDI, Coding, Physician Advisors, Quality, and Denials teams together for a shared review of denied sepsis cases and readmitted sepsis patients to identify overlapping documentation and risk-adjustment vulnerabilities.

Leadership Reflection

When we review sepsis cases, are clinical validation and quality performance discussed together, or do we continue to separate conversations about diagnosis support from conversations about outcome measurement and risk adjustment? ​​(CMS)

​

Week 9: Putting CDI and Coding at the Readmission Review Table

Focus: Applying documentation and coding expertise to readmission reviews.

Key Tenets

Readmission reviews should assess:

• Severe sepsis capture
• Septic shock capture
• Organ dysfunction representation
• Malnutrition documentation and coding
• Frailty documentation and coding
• Chronic condition capture

The goal is to understand both the patient’s clinical course and whether complexity was accurately represented in the record and coded data. ​​(CMS)​

Executive Indicators to Monitor

• Readmission review completion rate
• Documentation opportunities identified
• Coding opportunities identified
• Risk-adjustment findings from reviews

Action Item

Add CDI and Coding representation to existing sepsis readmission review processes and incorporate a standardized review of documentation integrity, code capture, risk-adjustment diagnoses, and discharge complexity.

Leadership Reflection

Do our readmission reviews focus solely on the reasons a patient returned to the hospital, or do they also evaluate whether documentation and coding accurately reflected the patient’s complexity at the time of discharge? ​(CMS)

​

Week 10: The Outcome Optimization Roadmap

Focus: Creating sustainable governance and accountability.

Key Tenets

Organizations should build a cross-functional model involving:

• CDI
• Coding
• Quality
• Physician Advisors
• Denials Management
• Revenue Integrity
• Care Management
• Population Health
• Medical Staff Leadership

Success requires shared ownership of documentation integrity, coding integrity, clinical validation, quality performance, and readmission outcomes. ​(CMS)​

Executive Indicators to Monitor

• Sepsis readmission rate
• Severe sepsis capture rate
• Septic shock capture rate
• Clinical validation denial rate
• Appeal overturn rate
• Frailty capture rate
• Documentation-to-code match rate
• Risk-adjustment completeness

Action Item

Develop a formal governance structure with shared ownership among CDI, Coding, Quality, Physician Advisors, Care Management, Denials Management, and Revenue Integrity. Establish metrics, reporting cadence, escalation paths, accountability, and annual goals for documentation integrity and outcome performance.

Leadership Reflection

One year from now, how will we know that our organization has successfully transitioned from documentation optimization to outcome optimization, and what metrics will demonstrate that clinically supported conditions are being documented, coded, validated, defended, and accurately reflected in our reported performance? ​​(CMS)​

Implementation Checklist

Organizations preparing for the finalized measure should consider the following actions:

• Establish a cross-functional governance structure
• Define shared metrics and ownership
• Reconcile clinically supported documentation with coded data
• Review sepsis severity, organ dysfunction, malnutrition, frailty, and chronic condition capture
• Analyze denials and rebuttal letters for recurring vulnerabilities
• Include CDI and Coding in readmission reviews
• Engage Physician Advisors and physician champions
• Report findings and trends to executive leadership
• Use findings to improve documentation, coding, validation, defense, discharge readiness, and care transitions

Final Takeaway

The finalized CMS Sepsis Readmission Measure signals a fundamental evolution of CDI. Organizations that continue to view CDI solely through the lens of MS-DRG optimization may miss a significant opportunity. ​(CMS)​

As quality measurement increasingly evaluates what happens after discharge, CDI programs can help ensure hospitals receive appropriate credit for the complexity of patients they serve while helping identify opportunities to reduce avoidable readmissions. ​(CMS)​

The most successful organizations will build strong partnerships among:

• CDI
• Coding
• Quality
• Physician Advisors
• Care Management
• Denials Management

Together, these groups can ensure that clinically supported conditions are:

Documented, coded, validated, defended, and accurately reflected in the data CMS uses to evaluate hospital performance.

Because in the era of outcome-based measurement:

Documentation is not the finish line. Accurate representation of the patient through coded data is. ​(CMS)

​

And perhaps most importantly:

Documentation is no longer only a reimbursement strategy. It is a coding strategy, a quality strategy, a readmission strategy, and a public reporting strategy. ​(CMS)

​

Resource:

Centers for Medicare & Medicaid Services: (August 4, 2026). FY 2027 IPPS Final Rule Home Page. Retrieved from: FY 2027 IPPS Final Rule Home Page | CMS

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The 2026 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice represent more than a routine update. They redefine compliant querying for a healthcare environment increasingly influenced by clinical validation reviews, risk adjustment, quality reporting, and AI-driven documentation tools.

Several key themes emerge from the new guidance.

Here are nine key changes every organization should know:

1. Compliant querying now extends well beyond inpatient CDI. Quality professionals, case management professionals, utilization management professionals, HCC coders, revenue cycle teams, consultants, vendors, and technology platforms generating documentation clarification requests are all expected to meet the same core requirements. If a communication functions as a query, it should comply as a query.
2. The guidelines introduce the concept of substantial compliance. This recognizes that minor technical deviations should not automatically render a query noncompliant when core principles are met.
3. The guidelines are not a stand-alone basis for denials or audit findings. The document explicitly states they should not be used alone to justify claim denials, payment recoveries, or adverse audit findings.
4. Providers retain full authority over clinical indicators. There is no required number of indicators needed to support a query, and providers ultimately determine clinical significance.
5. Query titles must remain neutral. Visible query names cannot direct providers toward a specific diagnosis. For example, “CDI Provider Query: Respiratory Status” is compliant, while “Query for Acute Hypoxic Respiratory Failure” is not.
6. The same compliance standards now explicitly apply to technology. This includes CAPD, CAC, AI-generated queries, EHR alerts, prompts, nudges, and large language model applications.
7. Organizations must govern their query technology. This means providing oversight, auditing, governance, and education for any tool that generates documentation clarification requests.
8. Reviewing prior encounters is appropriate, within limits. Looking back to establish baseline conditions, support specificity, or clarify active versus historical diagnoses is appropriate when supported by a current clinical trigger.
9. Systematically “mining” prior records is not appropriate. Searching prior records solely to import diagnoses into the current encounter falls outside compliant practice.

Ultimately, the 2026 update reflects healthcare’s movement toward clinical validity, defensible documentation, and ethical data integrity. Query practice is no longer simply a CDI function. It is an enterprise-wide responsibility requiring collaboration among CDI, coding, quality, compliance, physician leadership, and technology teams.

Leadership Question: If your AI-generated prompts, HCC clarification requests, CDI queries, and quality documentation reviews were audited today, would they all meet the same compliant query standards?

The 2026 ACDIS/AHIMA Query Practice Guidelines have officially expanded compliant querying beyond CDI. AI-generated prompts, HCC clarification requests, quality documentation reviews, and technology-assisted queries are now clearly within scope.

Key takeaway: If it functions like a query, it must comply like a query.

Is your organization ready?

Reference:

American Health Information Management Association and HCPro, LLC. (2026). Guidelines for Achieving a Compliant Query Practice. Retrieved 8/25/2026 from: ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice—2026 Update | ACDIS

Sepsis Blog Series: Part 2

Understanding CMS’s New Sepsis Readmission Measure

Healthcare leaders have long recognized that sepsis does not end when a patient leaves the hospital. Recovery often extends weeks or months beyond discharge, requiring coordinated clinical management, patient education, and effective transition planning. In the FY 2027 IPPS/LTCH PPS Final Rule, CMS finalized the Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate Following Sepsis Hospitalization Measure, marking a significant expansion of accountability within the Hospital Readmissions Reduction Program (HRRP). The measure reflects CMS’s growing focus on care transitions, patient outcomes, and comprehensive management of complex conditions following discharge. [1]

Why CMS Adopted the Sepsis Readmission Measure

Sepsis remains one of the leading causes of hospitalization, mortality, and healthcare utilization among Medicare beneficiaries. CMS developed this measure to provide meaningful information about hospital-level performance related to unplanned readmissions following a sepsis hospitalization.

The measure supports several key objectives:

• Improve patient outcomes following sepsis hospitalization
• Increase transparency regarding hospital readmission performance
• Encourage standardized evidence-based clinical care
• Strengthen discharge planning and post-discharge interventions
• Promote care coordination across the continuum of care
• Provide consumers and policymakers with actionable quality data [1]

CMS noted that the measure aligns with the Meaningful Measures 2.0 priority area of “Seamless Care Coordination,” emphasizing the importance of timely, coordinated care that reduces errors, prevents avoidable readmissions, and improves patient outcomes. [1]

Timeline for Implementation

While the original proposal referenced adoption beginning with the FY 2029 program year, CMS finalized a modified implementation approach:

• FY 2028 and FY 2029: Early-look confidential reports
• FY 2030: Measure begins use within the Hospital Readmissions Reduction Program for payment purposes [1]

This phased approach provides hospitals time to evaluate performance, identify opportunities for improvement, and strengthen sepsis transition-of-care programs before financial implications begin.

Measure Population

The Sepsis Readmission Measure includes:

• Medicare Fee-for-Service beneficiaries
• Medicare Advantage beneficiaries
• Age 65 years and older
• Patients discharged alive following a principal diagnosis of sepsis, including post-procedural sepsis
• Patients admitted to non-federal short-term acute care hospitals [1]

Notably, inclusion of Medicare Advantage beneficiaries supports CMS’s broader strategy of measuring quality consistently across the Medicare population. This aligns with previously finalized policies integrating Medicare Advantage patients into HRRP measurement cohorts. [1]

Understanding the Numerator

The numerator captures beneficiaries discharged following a qualifying sepsis hospitalization who experience an unplanned readmission to an acute care hospital for any cause within 30 days of discharge.

Beneficiaries must meet the following requirements:

• Age 65 or older
• Medicare enrollment during the index hospitalization
• Continuous Medicare enrollment during the prior 12 months
• Discharge alive from a non-federal short-term acute care hospital
• No transfer to another acute care facility

Importantly, only unplanned acute inpatient readmissions count toward the measure. Planned readmissions are excluded because CMS does not consider them a reflection of poor care quality. [1]

Understanding the Denominator

The denominator includes all eligible Medicare beneficiaries who:

• Are 65 years or older
• Have a principal diagnosis of sepsis (including post-procedural sepsis)
• Are discharged alive from a non-federal short-term acute care hospital
• Maintain continuous Medicare enrollment for 12 months before the index admission [1]

Key Exclusions

Several exclusions help ensure hospitals are assessed fairly:

• Patients leaving against medical advice (AMA): These patients are excluded because providers may not have had the opportunity to complete treatment or adequately prepare the patient for discharge. [1]
• Insufficient post-discharge enrollment: Patients without at least 30 days of Medicare enrollment following discharge are excluded because readmission outcomes cannot be fully evaluated. [1]
• Hospice discharges: Patients discharged to hospice are excluded because readmission is generally not considered an appropriate quality outcome in end-of-life care. [1]
• Overlap with the pneumonia readmission measure: Certain sepsis admissions already captured under CMS’s pneumonia readmission measure are excluded to prevent double counting. [1]
• Repeat sepsis admissions within 30 days: Sepsis admissions occurring within 30 days of an eligible index sepsis hospitalization are treated as readmissions, not new index admissions. [1]
• Strategic Implications for Hospitals

The finalized measure shifts attention beyond inpatient sepsis treatment and toward what happens after discharge. Organizations will likely need to strengthen the following areas.

1. Care transition programs

• Sepsis-specific discharge pathways
• Medication reconciliation
• Follow-up appointment scheduling
• Patient and caregiver education

2. Post-discharge monitoring

• Early outreach programs
• Remote monitoring initiatives
• Transitional care management

3. Clinical documentation improvement (CDI)

CDI teams should ensure:

• Accurate principal diagnosis assignment
• Appropriate sepsis documentation
• Complete capture of severity and risk factors
• Reliable coding to support accurate risk adjustment

4. Readmission prevention efforts

Hospitals may benefit from:

• Sepsis navigator programs
• Multidisciplinary discharge rounds
• Enhanced physician-hospital-provider communication
• Partnerships with post-acute providers

5. What CDI and quality leaders should do now

As hospitals review the FY 2027 Final Rule, CDI, quality, case management, and physician advisor teams should begin evaluating:

• Current sepsis readmission performance
• Existing discharge planning workflows
• Root causes of 30-day returns
• Opportunities for earlier post-discharge intervention
• Data analytics capabilities for sepsis outcomes tracking

The early-look reporting period provides valuable time to establish baseline performance and build improvement strategies before the measure affects HRRP payment calculations.

Bottom Line

CMS’s new Sepsis Readmission Measure represents a significant evolution in hospital accountability. By focusing on 30-day outcomes following sepsis hospitalization, CMS is emphasizing that quality sepsis care extends beyond the inpatient stay and includes successful recovery across the entire care continuum. Hospitals that invest now in care coordination, discharge planning, and post-discharge support will be better positioned to improve patient outcomes and succeed under future HRRP requirements. [1]

Reference:

[1] Centers for Medicare & Medicaid Services. (July 31, 2026).

FY 2027 Hospital Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System Final Rule (CMS-1849-F). Retrieved from https://www.cms.gov/newsroom/fact-sheets/fy-2027-hospital-inpatient-prospective-payment-system-long-term-care-hospital-prospective-payment

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Common ED Procedures

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Operations on the Hand

Hospitals across the country will soon face a new level of accountability for joint replacement care. As part of the FY 2027 IPPS Final Rule, CMS finalized the Comprehensive Care for Joint Replacement Expanded (CJR-X) Model, marking the first mandatory nationwide episode-based payment model in Medicare. The program will begin January 1, 2028, a three-month delay from the originally proposed October 1, 2027, start date. [2], [hfma.org]

What is CJR-X?

CJR-X builds on the success of the original Comprehensive Care for Joint Replacement (CJR) Model and is designed to improve care coordination for Medicare beneficiaries undergoing lower extremity joint replacement procedures. The model includes hip, knee, and ankle replacements performed in hospital settings. [2]

Under CJR-X, participating hospitals will be held financially accountable for the entire episode of care, including:

• The joint replacement procedure
• The hospitalization
• All Medicare-covered services during the first 90 days after discharge, such as rehabilitation and physical therapy

The goal is to encourage hospitals, surgeons, and post-acute providers to work together to deliver high-quality, coordinated care while reducing avoidable complications, readmissions, and unnecessary spending. [2]

Why CMS Is Expanding the Model

CMS is expanding the model based on the results of the original CJR program, which operated from April 2016 through December 2024. According to CMS, the program generated more than $100 million in Medicare savings while maintaining quality of care, demonstrating that coordinated, episode-based payment models can improve efficiency without compromising patient outcomes. [2], [1]

CMS leaders have emphasized that CJR-X aligns financial incentives with patient outcomes, rewarding hospitals that successfully coordinate care throughout the recovery period rather than focusing solely on the surgical encounter. [cms.gov], [cms.gov]

Who Will Participate?

Most hospitals paid under the Inpatient Prospective Payment System (IPPS) and the Outpatient Prospective Payment System (OPPS) will be required to participate. However, CMS finalized several exemptions including:

• Hospitals participating in the Transforming Episode Accountability Model (TEAM)
• Hospitals located in Maryland
• Hospitals not paid under both the IPPS and OPPS payment systems

These exemptions are intended to avoid overlapping payment models and account for unique state payment structures. [hfma.org], [1]

What This Means for Hospitals

With CJR-X, hospitals will need to strengthen partnerships across the continuum of care, including physicians, rehabilitation providers, skilled nursing facilities, and home health agencies. Organizations that can effectively manage recovery, reduce complications, and prevent avoidable utilization will be better positioned to succeed financially under the model. [2]

For clinical and quality leaders, the model reinforces the ongoing industry shift from fee-for-service reimbursement toward value-based care, where success is measured not only by the procedure itself but by the patient’s overall recovery experience and outcomes. [2]

Bottom Line

Beginning in 2028, CJR-X will make episode-based payment for joint replacements a nationwide reality. By holding hospitals accountable for care from surgery through 90 days of recovery, CMS aims to improve coordination, enhance patient outcomes, and reduce unnecessary Medicare spending. The model’s nationwide expansion signals CMS’s continued commitment to value-based care and may serve as a blueprint for future episode-based payment initiatives. [2]

References:

1. Condon, Alan. (August 3, 2026). CMS finalizes 2.3% hospital pay bump, mandatory joint replacement model: 9 things to know. Becker’s Hospital Review. Retrieved from: https://www.beckershospitalreview.com/finance/cms-finalizes-2-3-hospital-pay-bump-mandatory-joint-replacement-model-9-things-to-know/.
2. Centers for Medicare & Medicaid Services. (July 31, 2026). CJR-X (Comprehensive Care for Joint Replacement Expanded) Model. Retrieved from: CJR-X (Comprehensive Care for Joint Replacement Expanded) Model | CMS
3. Hut, Nick. (August 2, 2026). CJR-X mandatory bundled payment model begins for hospitals in 2028. Healthcare Financial Management Association. Retrieved from: https://www.hfma.org/payment-reimbursement-and-managed-care/cjr-x-mandatory-bundled-payment-model/.

Michael Trelow, our Director of Trauma Quality, is leading a session on Anticoagulants and Reversal Agents. This is one of the most complex and frequently misunderstood areas of trauma abstraction.

Objectives:

• Review NTDS Anticoagulation Rules
• Discuss how each anticoagulant category works
• Review reversal agents

To download the slides for this presentation, click here!

In the fast-paced world of trauma care, every second counts. Behind the scenes, trauma registry data management plays a major role in transforming raw patient data into actionable insights that save lives. Trauma registries collect detailed data on injured patients, from the moment of injury through treatment and discharge. However, the true power of these registries lies not just in data collection but in how that data is managed, validated, and utilized.

Poor data management can lead to incomplete records, inaccurate benchmarking, and missed opportunities for quality improvement. Conversely, strong practices enhance performance improvement initiatives, support research, and help trauma centers maintain verification from bodies like the American College of Surgeons (ACS). This article explores the critical importance of trauma registry data management, its challenges, best practices, and future directions.

We will discuss the key factors that demonstrate why effective trauma registry data management is vital for improving patient outcomes, ensuring compliance, and advancing trauma care, while exploring best practices and strategies to help you optimize your registry today.

What Is a Trauma Registry and Why Does Data Management Matter?

A trauma registry is a specialized database that captures comprehensive information about trauma patients, including demographics, injury mechanisms, pre-hospital care, diagnoses, treatments, outcomes, and complications. These registries feed into larger systems like the National Trauma Data Bank (NTDB) and the Trauma Quality Improvement Program (TQIP).

Trauma registry data management encompasses the entire lifecycle of the following information:

• Collection
• Entry
• Validation
• Storage
• Analysis
• Reporting

Effective management ensures:

• Data Accuracy
• Completeness
• Timeliness
• Consistency

Accurate data drives evidence-based changes in clinical protocols, reduces mortality, and identifies injury prevention opportunities. For instance, registries have contributed to significant declines in trauma-related death and disability rates by enabling systems-level improvements.

Without proper management, registries risk becoming repositories of unreliable information, undermining their potential to inform policy, research, and care delivery.

The Impact of Strong Data Management on Patient Outcomes

High-quality trauma registry data management directly correlates with better patient care. Trauma teams rely on registry data to track outcomes, spot trends, and implement performance improvement (PI) projects. When data is accurate, clinicians can identify gaps early—such as delays in care or higher-than-expected complication rates, and adjust accordingly.

Consider a hospital analyzing ventilator-associated pneumonia rates. Reliable data allows for precise risk adjustment using injury severity scores and comorbidities. This leads to targeted interventions that lower infection rates and shorten hospital stays. Studies show that well-managed registries support benchmarking against national standards, fostering competition and continuous improvement across trauma centers.

Key Challenges in Trauma Registry Data Management

Despite its importance, trauma registry data management faces several hurdles:

• Manual Processes and Workload: Many registrars still manually abstract data from electronic health records (EHRs), a time-intensive task prone to errors. High patient volumes strain staffing, leading to backlogs.
• Data Quality Issues: Inconsistent documentation, varying definitions, and interpretation differences can compromise accuracy. Incomplete records or coding errors affect risk-adjusted outcomes and benchmarking validity.
• Interoperability and Technology Gaps: Fragmented systems exacerbate seamless data exchange between EMS, hospitals, and state registries. Legacy software often lacks robust validation tools.
• Staffing and Training: Qualified trauma registrars with certifications like Certified Specialist in Trauma Registry (CSTR) or Certified Abbreviated Injury Scale Specialist (CAISS) are in short supply. Ongoing education is crucial but resource intensive.
• Compliance and Privacy: Meeting NTDS standards, state requirements, and HIPAA regulations add complexity while protecting HIPAA.

These challenges can result in delayed reporting, failed verifications, or flawed research, emphasizing the need for strategic data management.

The Trauma Registry Data Lifecycle

Best Practices for Effective Trauma Registry Data Management

Successful programs adopt a proactive, multifaceted approach to data management.

1. Implement a Comprehensive Data Quality Plan: ACS standards require trauma centers to maintain a formal data quality plan, including validation methods, inter-rater reliability (IRR) checks, and audits. Aim for at least 10% IRR monthly and accuracy rates of 90-95% or higher. (Source 1)
2. Leverage Technology and Automation: Modern registry software offers real-time validation, auto-population from EHRs and EMS records, and customizable rules. Electronic data transfer reduces manual entry, allowing registrars to focus on complex coding and validation. Remember that electronic data transfers require validation.
3. Standardize Processes with NTDS and Data Dictionaries: Adhere strictly to the National Trauma Data Standard for consistent definitions. Use audit filters to flag potential errors, such as high injury severity scores without documented complications. Create a hospital-based data dictionary that includes where in the EHR you will pull the data from.
4. Invest in Staff Development: Provide thorough training, mentorship (especially for Level III/IV centers), and career advancement. Encourage certifications and foster a culture where all clinical staff understand the value of quality documentation.
5. Conduct Regular Validation and Analysis: Combine software checks with peer reviews and external benchmarking via TQIP. Generate reports on completeness, timeliness, and logic errors to drive improvements.
6. Ensure Interoperability and Security: Prioritize systems that support seamless data exchange while maintaining cybersecurity and privacy protections.

By following these practices, centers can turn data management from a compliance burden into a strategic asset.

The Role of Data Management in Research and Injury Prevention

Beyond immediate clinical use, trauma registry data management drives research and prevention. Clean, detailed datasets enable studies on injury patterns, treatment efficacy, and long-term outcomes. Researchers can explore topics like the impact of pre-hospital interventions or disparities in rural versus urban care.

Public health agencies use aggregated data to identify high-risk areas or behaviors, such as distracted driving or falls among the elderly. This informs targeted campaigns that reduce injury incidence. Strong data management ensures these analyses are credible and generalizable.

Conclusion: Prioritizing Trauma Registry Data Management

Effective trauma registry data management is not optional; it is foundational to high-quality trauma care. It empowers providers to deliver better outcomes, supports regulatory compliance, advances research, and contributes to safer communities. Hospitals and systems that invest in people, processes, and technology reap significant rewards in terms of patient survival, operational efficiency, and institutional reputation.

As trauma care continues to advance, those committed to high quality in data management will lead the way. Trauma program leaders should assess their current practices, invest in training and tools, and develop a data-driven culture. The lives saved through these efforts make the investment invaluable.

Contact us to learn more about how Velarity HCS can help with every aspect of data management, from staffing to gap analysis.

Source:

(1) Resources for Optimal Care of the Injured Patient 2022 Standards, 6.1 Data Quality Plan

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Tip Card: The Relationship Between Ferritin, Hemoglobin, and Total Iron

Heart failure documentation is entering a new era, and “CHF” is no longer enough.

The 2026 AHA/ACC/ESC/WHF Second Universal Definition of Heart Failure reinforces what CDI and Coding professionals have long known: accurate heart failure capture depends on specificity. While this update does not introduce new ICD-10-CM codes, it does signal an important shift in clinical language and documentation expectations.

As clinical definitions evolve to better reflect heart failure type, acuity, etiology, ejection fraction phenotype, and disease trajectory, documentation must evolve as well. For CDI teams, this creates an opportunity to strengthen provider education, improve query impact, and support more accurate severity, quality, and risk adjustment reporting. For Coding teams, it reinforces the need for clear provider documentation that supports precise code assignment using existing code sets.

The future of heart failure documentation is not simply identifying that heart failure exists. It is clearly documenting what kind, why it occurred, how active it is, and where the patient is on the disease continuum.

Key CDI Implications

1. Documentation Must Be More Specific Than “CHF”

While “CHF” remains common in documentation, it is increasingly insufficient for accurate CDI review and coding.

 The updated definition reinforces the need to document:

• Heart failure phenotype
• Etiology or underlying cause
• Stage or disease continuum
• Acute versus chronic status
• Improvement, remission, or recovery status

Instead of documenting only “CHF,” providers should be encouraged to specify:

• HFrEF due to ischemic cardiomyopathy
• HFpEF is secondary to hypertensive heart disease
• Heart failure with improved EF following guideline-directed medical therapy
• Acute chronic systolic heart failure

The updated definition’s emphasis on classifying heart failure causes makes etiologic specificity increasingly important. [1,2]

CDI Query Opportunities

Heart failure documentation may support a query when clinical indicators are present but documentation lacks clarity regarding:

• • Type of heart failure
  • Acute, chronic, or acute-on-chronic status
  • Etiology or underlying cause
  • Relationship to hypertension, CAD, valvular disease, amyloidosis, cardiomyopathy, or treatment-related causes
  • Whether heart failure remains active, improved, in remission, or recovered

The key CDI question becomes:

Does the documentation tell the complete clinical story of the patient’s heart failure?

2. Increased Focus on Pre-HF and Earlier Identification

The universal definition continues to recognize patients with structural heart disease, biomarker abnormalities, or cardiac dysfunction without classic symptoms as being in a pre-heart failure stage. [1,4]

From an inpatient CDI perspective, pre-HF may not typically drive MCC or CC capture. However, it is increasingly relevant to:

• Ambulatory CDI
• Population health
• Risk stratification
• Longitudinal condition monitoring
• Provider education
• Early disease progression tracking

For organizations expanding outpatient CDI or risk adjustment work, this concept may become more important over time.

3. Heart Failure Can Improve, Remit, or Recover

A major documentation implication is the recognition that heart failure is dynamic. Patients may experience improvement, remission, or recovery rather than remaining in a fixed disease state. [1–3]

This matters because vague statements such as “history of CHF” may not accurately describe a patient whose heart failure remains clinically active and managed.

Documentation may need to distinguish between:

• Active heart failure with improved EF
• Heart failure in remission
• Recovered EF after treatment
• Historical heart failure with no current treatment or monitoring

For CDI and Coding teams, this distinction affects severity capture, risk adjustment, clinical communication, and longitudinal documentation accuracy.

Key Coding Implications

1. EF Classification Language Is Evolving

The updated definition moves away from overly rigid ejection fraction cutoffs and broadly recognizes heart failure phenotypes such as:

• Reduced EF
• Preserved EF
• Improved EF

The document also acknowledges that patient-specific factors may influence interpretation of EF and disease phenotype. [1,2]

From a coding perspective, ICD-10-CM codes have not automatically changed because of this clinical definition update. Coders should continue assigning heart failure codes based on provider documentation.

However, CDI teams should anticipate evolving terminology from cardiology societies and monitor for potential future coding guidance changes.

2. Etiology Matters More Than Ever

The updated universal definition emphasizes classification of heart failure causes. This is highly relevant for CDI and Coding because cause-and-effect documentation can support more complete code assignment and clinical specificity. [1,2]

Examples include:

• Hypertensive heart disease with heart failure
• Ischemic cardiomyopathy with heart failure
• Valvular heart disease with heart failure
• Amyloid cardiomyopathy with heart failure
• Chemotherapy-induced cardiomyopathy with heart failure

For coding accuracy, the provider must clearly document the relationship between heart failure and the underlying condition when required.

3. Risk Adjustment and Quality Reporting Implications

Although the universal definition is clinical rather than coding-specific, improved heart failure specificity supports many CDI and Coding priorities, including:

• Accurate HCC capture
• Improved severity of illness representation
• More accurate mortality prediction
• Better quality reporting
• Improved communication across the care continuum [2,5]

Documentation that clearly identifies heart failure type, acuity, severity, etiology, and trajectory remains essential for both inpatient CDI and outpatient risk adjustment work.

CDI Educational Takeaways

For CDI education, five key messages should be emphasized:

1. Stop Accepting “CHF” as Complete Documentation

Providers should be encouraged to document heart failure type, acuity, etiology, EF phenotype, and clinical trajectory.

2. Capture the Cause

CDI teams should ask:

What caused the heart failure?

The answer may involve hypertension, ischemic disease, valvular disease, cardiomyopathy, infiltrative disease, treatment-related causes, or other clinical conditions.

3. Document Improvement, Remission, or Recovery

Heart failure status should reflect current clinical reality. If the patient has improved EF, remission, or recovery, that distinction should be documented clearly.

4. Think Longitudinally

Heart failure is increasingly viewed as a disease continuum rather than a single encounter diagnosis. This is especially important for ambulatory CDI, HCC education, and population health programs.

5. Prepare for Future Coding Evolution

Current ICD-10-CM code families remain in use, but CDI and Coding teams should monitor future coding guidance as clinical terminology continues to evolve.

Bottom Line for CDI Leaders

• The biggest CDI and Coding message from the 2026 Universal Definition of Heart Failure is not a new ICD-10-CM code.
• It is the expectation of greater clinical specificity.
• Organizations should begin reinforcing provider documentation that includes:
• Heart failure type + acuity + etiology + EF phenotype + disease trajectory
• This aligns directly with CDI goals related to severity capture, quality measurement, risk adjustment accuracy, provider education, coding consistency, and clearer clinical communication.

The documentation opportunity is not simply to code heart failure. It is to tell the full clinical story.

References

1. AHA/ACC/ESC/WHF. Second Universal Definition of Heart Failure, 2026. Referenced summary and professional society publication materials.
2. American College of Cardiology. Heart failure definition and classification updates. ACC.org.
3. European Heart Journal / Oxford Academic. Universal definition of heart failure publication materials. Academic.oup.com.
4. American Heart Association Professional Heart Daily. Heart failure stages and prevention-focused clinical framework. professional.heart.org.
5. American Heart Association Newsroom. Heart failure classification, risk, and quality-related reporting context. newsroom.heart.org.

CDI as an Enterprise Quality Strategy

The New Measure of Success

The conversation in CDI is changing.

For years, CDI programs measured success through familiar metrics such as query volume, CC/MCC capture, Case Mix Index (CMI), and financial impact. While these metrics remain important, they no longer fully capture the value CDI delivers to healthcare organizations operating in an environment increasingly shaped by quality reporting, risk adjustment, value-based reimbursement, and regulatory oversight. CMS value-based programs explicitly tie reimbursement to quality, outcomes, patient safety, and efficiency rather than volume alone. [dexur.com], [hhs.gov]

As reimbursement continues to shift toward quality and value-based care models, CDI has evolved from a documentation-focused function to a strategic enterprise partner influencing quality scores, compliance risk, physician engagement, risk adjustment, and financial sustainability. [dexur.com], [hcahpsonline.org]

From Documentation Improvement to Performance Improvement

The modern CDI leader’s role extends far beyond chart reviews and query management.

Understanding Hospital Star Ratings, risk-adjusted mortality, readmissions, Hospital-Acquired Conditions (HACs), PSI-90 measures, and Value-Based Purchasing allows CDI professionals to influence outcomes that matter to patients, providers, executives, and regulators. CMS Hospital Value-Based Purchasing measures include mortality, complications, healthcare-associated infections, patient safety, patient experience, and efficiency. All of these areas are heavily influenced by the accuracy of clinical documentation. [hhs.gov], [hcahpsonline.org]

Documentation serves as the foundation for coded data, quality reporting, risk adjustment, reimbursement, and compliance activities. AHIMA and ACDIS identify CDI as a multidisciplinary function that affects quality outcomes, mortality measures, coding accuracy, reimbursement, medical necessity, risk adjustment, and compliance. [acdis.org], [cdiplus.com]

When documentation accurately reflects patient complexity and clinical decision-making, organizations can:

• Improve risk adjustment accuracy
• Strengthen quality reporting
• Reduce denials and audit risk
• Enhance physician communication
• Support compliance initiatives
• Improve value-based reimbursement performance

In this environment, CDI is no longer a supporting function, it is a strategic business partner. [acdis.org], [dexur.com]

The Enterprise CDI Ecosystem

Revenue Cycle

CDI ensures documented severity accurately reflects patient complexity, supporting compliant reimbursement while reducing opportunities for payer denials, retrospective audits, and clinical validation disputes. [acdis.org], ​[All CDI Status | Excel]​

AHIMA and ACDIS tie this work directly to:

• Denial prevention
• Clinical validation success
• Revenue integrity
• Reduction in retrospective appeals

Quality

Quality leaders depend on accurate documentation to support risk-adjusted outcomes and publicly reported measures.

Documentation accuracy directly influences:

• Hospital Star Ratings
• Mortality performance
• Readmission performance
• HAC reduction
• PSI-90 outcomes

These measures shape both public reporting and reimbursement under CMS quality programs. [hhs.gov], [dexur.com]

Compliance

As organizations face increasing regulatory scrutiny and payer reviews, CDI plays a critical compliance role.

The AHIMA/ACDIS Guidelines for Achieving a Compliant Query Practice call for:

• Clinically valid documentation
• Compliance with coding regulations
• Audit-ready, defensible practices

Together, these reduce an organization’s overall compliance exposure. [acdis.org], [cdiplus.com]

HIM and Coding

Many organizations now treat CDI and coding as components of a single documentation integrity strategy. [acdis.org], ​[All CDI Status | Excel]​

AHIMA and ACDIS identify this collaboration as essential to:

• Coding accuracy
• Data integrity
• Fewer DRG disputes
• Consistent clinical interpretation

Physician Leadership

Physician advisors, CMOs, and physician champions rely on CDI teams to bridge the gap between clinical practice and documentation requirements. [acdis.org], [cdiplus.com]

AHIMA/ACDIS query guidance centers physician engagement as key to:

• Provider adoption
• Sustainable documentation behaviors
• Reduced educational rework

Population Health and Risk Adjustment

As healthcare shifts toward value-based care, CDI programs are expanding beyond the inpatient encounter. [dexur.com], [hhs.gov]

CMS value-based programs build in:

• Accurate patient risk profiles
• Improved care management strategies
• Enhanced value-based reimbursement outcomes

These measures align directly with the outcomes emphasized throughout CMS quality and value-based purchasing programs. [hhs.gov], [dexur.com]

The most important shift is that CDI is no longer measured solely by activity.

It is measured by influence.

The new measure of success is not how many queries were written, but how effectively CDI improves organizational outcomes.

Conclusion

The question is no longer whether CDI professionals should understand CMS quality measures, value-based reimbursement, and organizational performance metrics.

The question is whether healthcare organizations can afford for them not to.

Hospital Star Ratings, mortality measures, readmissions, HACs, PSI-90, value-based purchasing, denials, and compliance risk all begin with the same thing: the clinical story documented in the health record. CMS quality programs tie these outcomes directly to organizational performance and reimbursement. [hhs.gov], [dexur.com]

When that story is incomplete, organizations risk inaccurate quality reporting, missed opportunities for appropriate risk adjustment, increased denials, and weakened value-based performance. AHIMA and ACDIS identify clear, accurate, clinically valid documentation as foundational to quality, coding, reimbursement, compliance, and risk adjustment efforts. [acdis.org], ​[All CDI Status | Excel]

References

1. CMS Value-Based Programs. [dexur.com]
2. CMS Hospital Value-Based Purchasing Program. [hhs.gov], [hcahpsonline.org]
3. AHIMA/ACDIS Guidelines for Achieving a Compliant Query Practice (2022 Update). [acdis.org], [cdiplus.com]
4. AHIMA/ACDIS Guidelines for Achieving a Compliant Query Practice (2019 Update). ​[All CDI Status | Excel]

Missed our July webinar? Access the recording and slides today!

This webinar featured special guest Kevin Shovlin, MBA, BSN, RN, TCRN, CHFP, NE-BC — Account Executive & Trauma Product Specialist.

The trauma registrar is far more than a data entry role, and this session proves it.

Kevin will walk through how trauma registrars can step into their full potential as active contributors to Performance Improvement, covering:

• Describe the registrar’s active PI role beyond data entry, including concurrent abstraction, clinical rounding, shift handoffs, and PIPS committee engagement.
• Identify ACS-COT standards 6.1 and 7.2 and explain registrar accountability within each.
• Compare retrospective vs. concurrent review and explain why concurrent abstraction yields more accurate, actionable PI data.
• Demonstrate how audit filter reports, complication trends, and benchmark outliers are used to identify and scope PI projects.
• Explain how to expand the trauma registry beyond the NTDS minimum dataset to support guideline compliance, TQIP optimization, and research.

Whether you’re a trauma registrar, PI coordinator, or trauma program leader, this is a session you won’t want to miss.

To download the slides for this presentation, click here!

Cancer registry leaders are frequently asked a simple question:

“How many cases should an Oncology Data Specialist (ODS) complete each day?”

Unlike many healthcare departments, cancer registries do not have a universally accepted productivity model. The work of the ODS does not generate relative value units (RVUs) or other traditional performance metrics, making completed cases the most common metric used to evaluate performance. However, case counts alone fail to capture the complexity of registry work or the full scope of an ODS’s responsibilities.

Rather than promoting a universal standard, this article presents a practical framework that measures the time required to complete the three core registry functions associated with a completed case:

Casefinding + Abstracting + Follow up = ODS Abstracting Productivity

The goal is to establish realistic productivity expectations while maintaining complete, accurate, and timely cancer registry data.

One Completed Abstract Requires Dozens of Coding Decisions:

The ODS must interpret complex clinical documentation and apply multiple national coding guidelines and staging standards that are continually updated, including:

• Solid Tumor Rules
• Hematopoietic and Lymphoid Neoplasm Rules
• SEER Program Coding and Staging Manual
• Grade Coding Instructions
• STORE Manual
• AJCC Staging
• ICD O 3
• SEER Summary Staging
• Site Specific Data Item (SSDI) Manual
• Extent of Disease (EOD) Manual
• State specific reporting requirements
• Treatment Specific Coding Manuals

In addition to national standards, many organizations require collection of institution specific data elements to support accreditation, quality improvement, physician performance reporting, research, and strategic initiatives. These additional responsibilities further influence the time required to accurately complete each case.

Productivity Extends Beyond Abstracting

Abstracting is only one component of the Oncology Data Specialist’s workload.

Depending on the organization, ODS staff may also be responsible for:

• Casefinding
• Follow up activities
• Quality assurance reviews
• Physician queries
• Resolving pathology discrepancies
• Managing suspense files
• Correcting state edits errors
• Registry software maintenance
• Tumor Board
• Accreditation and Cancer Committee activities
• State registry submissions
• Research support
• Data requests and analytics

Each of these responsibilities reduces the amount of time available for abstract completion and should be considered when establishing productivity expectations.

Not Every Cancer Case Requires the Same Amount of Time:

One of the greatest challenges in measuring productivity is the variation in case complexity.

Factors that significantly influence abstraction time include:

• Multiple primaries
• Complex treatment sequences
• Multiple reporting facilities
• Extensive diagnostic workup
• Numerous pathology specimens
• Biomarker and molecular testing
• Neoadjuvant therapy
• Disease recurrence
• Long hospitalizations
• Large volumes of physician documentation

For this reason, productivity should be measured using average hours per completed abstract, rather than a fixed number of cases per day. Our suggested expectation is an average of 2 hours per completed abstract.

Productivity Tracking Tool:

A simple tracking tool should include:

• Accession/MRN Number
• Primary Site/Sequence
• Class of Case
• Facility
• Date Abstracted
• Total Hours Worked
• Descriptive Comments (including complexity, reportability, multiple primaries, multiple facilities, extensive treatment, physician query, etc.)

Calculating ODS Production:

• Weekly Production Capacity:
  • Available Weekly ODS Production Hours ÷ Productivity Expectation (Hours per Completed Case) = Expected Completed Case Capacity
  • Example: 40 production hours ÷ 2 hours per completed case = 20 completed cases per week (on average)

• Backlog Completion Projection:
  • Backlog Cases ÷ Weekly Case Capacity = Weeks to Completion
  • Example: 500 backlog cases ÷ 20 completed cases per week = 25 weeks

• Staffing Projection:
  • Backlog Cases × Hours per Completed Case = Total Production Hours Required
  • Example: 500 cases × 2 hours = 1,000 production hours

Calculating ODS Productivity:

• Determine Expected Case Completion (Available ODS Production Hours ÷ Productivity Expectation (Hours per Completed Case) = Expected Completed Cases
  • Example: 40 production hours ÷ 2 hours per completed case = 20 expected completed cases
• Calculate Productivity Rate by ODS (Completed Cases × Productivity Expectation (Hours per Completed Case) ÷ Actual ODS Production Hours Worked = Productivity Rate
  • Example: (20 completed cases × 2 hours) = 40 hours ÷ 40 Available Weekly ODS Production Hours = 100% Productivity
    • Note: If someone spends 10 hours in meetings, QA, education, cancer committee preparation, etc., don’t use 40 hours in the denominator.

Productivity expectations should be based on actual abstracting time. Meetings, quality assurance, follow up, case finding, state reporting, accreditation activities, education, software issues, physician queries, and other assigned responsibilities reduce the number of hours available for abstract completion and should be considered when establishing productivity goals.

The Goal is Sustainable Performance:

Productivity should encourage efficiency while maintaining the integrity of cancer registry data.

Organizations that establish realistic productivity expectations and recognize differences in case complexity create a more sustainable work environment, improve staff retention, and produce higher quality registry data.

A productivity benchmark of approximately 2 hours per completed abstract can serve as a practical operational target for many cancer registry programs. However, no single benchmark is appropriate for every organization. Productivity expectations should be defined by the cancer program.

Take the first step today. Review one month of registry activity, calculate your team’s average hours per completed case, assess quality outcomes, and determine whether your current productivity expectations accurately reflect the work being performed.

Productivity is not measured by the number of abstracts completed. It is measured by the ability to consistently produce accurate, timely, and complete cancer registry data while maintaining a sustainable workload for your Oncology Data Specialists.

Not sure where to start?

Velarity’s Cancer Registry Operational Assessment provides a comprehensive evaluation of productivity, workflows, staffing, quality, and operational performance. Our experienced cancer registry leaders identify opportunities to improve efficiency, strengthen data quality, optimize staffing, and prepare your program for long-term success.

Whether you need an operational assessment, strategic consulting, interim leadership, or experienced Oncology Data Specialists, Velarity HCS delivers customized solutions that help cancer programs build stronger, more sustainable registry operations.

Couldn’t Join Us Live? Get Instant Access to the Recording & Slides

Led by Michael Trelow, CSTR, CAISS, this session was requested by our participants, and you won’t want to miss it!

• The importance of ICD-10-CM External Cause Codes in Trauma Registries
• Documentation guidelines
• Best practices & common pitfalls

Click here to download the slides!

Let’s be honest! What does Case Management and Utilization Review look like in your Emergency Department?

When a patient comes into the ED, I know the last thing on your mind is documentation strategy. You’re focused on the care of the patient in front of you, getting orders in, managing the family, coordinating with the team. I get it, I’ve been a part of the ED team.

But the reality is that denial rates are at all-time highs. According to HFMA, initial denials are up from 11.41% in 2024 to 11.65% in 2025. Healthcare Finance News reports that in 2025, approximately 2,300 hospitals reported denial-related losses of around $48 billion.

Those aren’t just revenue cycle numbers, that’s real money that was supposed to support real patient care, slipping away because of gaps that often start at admission.

Having worked across level 1 trauma centers, community hospitals, and emergency departments in roles spanning utilization review, discharge planning, complex care transitions, and case management leadership, I can say with confidence that most of these denials are preventable. And it starts with what happens in the first few hours of a patient’s stay.

Here is what we can accomplish when you have engaged Utilization Review (UR) nurses and a team of admitting physicians.

An Admission Order Alone Is Not Enough

A physician order to admit is just the beginning. What UR nurses need is the clinical picture, the acuity, the comorbidities, the reason this patient cannot be safely managed at a lower level of care. “Admit for chest pain” is a sentence. It’s not a story. Payers want to see why this patient, on this day, needed inpatient or observation-level care. The earlier you paint that picture, the better we can protect the stay.

Observation vs. Inpatient Is Not a Back-Office Decision

This is one of the biggest misconceptions I run into. Status designation isn’t something that should be sorted out later by billing. The clinical documentation from the admitting provider directly determines whether a patient qualifies for inpatient status. When clinical findings that support medical necessity are not documented at admission, retrospective clarification efforts can make it harder to support the inpatient level of care. When the documentation does not clearly support the inpatient order, the UR team is left coordinating provider clarifications, resubmitting clinicals, and working against a shortened timeline to obtain a payer determination while the patient is still in-house.

And let’s face it, retrospective work is costing additional dollars. Front-line UR nurses are typically overwhelmed with completing first-day and concurrent reviews, along with sending clinicals. Once that initial denial is issued, you need an experienced appeals team working the denial and assisting with setting up peer-to-peers, if offered. It would absolutely be best practice to prevent the initial denial if possible. Understanding that in this current environment that may not always be possible, it is also important to have a meticulous and highly proficient appeals and denials nurse supporting your team.

Don’t Forget the Comorbidities That Are Also Being Managed

Realistically, a patient admitted for pneumonia who also has COPD, Type 2 Diabetes, and heart failure is a completely different clinical picture than a patient with pneumonia alone. It’s a much more complex care plan that may require a longer length of stay. Every active condition being monitored or affecting treatment should be in the chart. For example, malnutrition is a diagnosis that sometimes gets under-documented. Depending on the documented severity, this could be the difference between a CC and an MCC that can directly impact the hospital’s reimbursement. These comorbidities help paint a complete picture of the patient’s clinical complexity and the level of care, monitoring, and resources required throughout the hospitalization. We can advocate much more effectively when the full complexity of your patient is visible.

The Emergency Department Is the Front Line of Admission Support

I see the ED as the front line in identifying patient needs and helping shape the trajectory of care. Understanding that everything moves fast in the ED, it is helpful to the UR team when providers are capturing the full picture of what is occurring with the patient. And let’s not forget the severity of illness while the patient may have been en route in the ambulance! Many times, this is when the patient is at the peak of their medical crisis and is receiving vital treatment. Patient Care Reports from EMTs can also help paint the picture of just how sick the patient is and why hospital care was necessary. Their initial assessment allows for a supported, defensible admission that will, in the long run, save the hospital money.

The Most Underutilized Partnership in Healthcare

UR nurses are not here to practice medicine or to create more work for an already stretched clinical team. Consider us your go-to resource when it comes to payer guidelines and an ally that helps with patient benefits and reimbursement. Our goal is to advocate for the patient — including their benefits — and part of that is making sure hospitals are appropriately reimbursed for the care delivered. When billions of dollars in revenue are lost, hospitals struggle to pay for basic needs to keep their doors open. According to the USDA Economic Research Service, between 2005 and 2023, over 140 rural hospitals closed their doors or were converted to non-acute care facilities. Becker’s reports that just this year, in 2026, 18 hospitals completed mergers and acquisitions with larger, more stable health systems. When these smaller rural hospitals close their doors, it’s the patients that suffer. Typically, it is at these hospitals where they can get lifesaving treatment quickly and then, if needed, transfer to higher levels of care.

The relationship between admitting physicians and UR professionals may be one of the most underleveraged partnerships in healthcare. When it works, everybody wins!

Whether you’re a utilization review nurse looking to sharpen your skills, an admitting provider seeking to better understand payer expectations, or a hospital leader focused on reducing denials, we’d love to connect.

We enjoy sharing insights on emerging trends, discussing common challenges, and learning what’s working across organizations.

Contact us today if you have any questions or inquiries!

Sources:

Cass, A. (2026, June12). 18 hospital M&A’s finalized in 2026. Becker’s Hospital Review.

Morse, S. (2026, April 2). Hospitals’ Net Revenue Leakage Increase 25% Due to Denial Claims. Healthcare Finance News.

Rupasingha, A., & Cho, J. (2025). Federal assistance and rural hospital closings: The impact of the USDA Community Facilities Program (Report No ERR-344). U.S. Department of Agriculture, Economic Research Service.

Williams, J. (2026, January 30). Battle of the Bots intensifies over denials. Healthcare Financial Management Association.

Missed our May webinar? Check out the recording and slides today!

Trauma programs manage an extraordinary volume of complex data, and effective data management is essential to ensure quality outcomes, regulatory compliance, and ongoing performance improvement.

In this session, Michael Trelow, Director of Trauma Quality, will share practical insights drawn from real‑world experience in trauma quality and data oversight.

Webinar objectives include:

• Describing why data management is critical
• Outlining the data management lifecycle in trauma registries
• Identifying best practices, common challenges, and technology solutions to support high‑quality trauma data

Click here to download the slides! 

We hosted a webinar for the Indiana chapter of ACDIS (the Association of Clinical Documentation Integrity Specialists), missed it? Watch the full recording here.

What is covered:

• Discuss what encephalopathy really means
• Showcase 3 types of encephalopathy
• Identify query opportunities for encephalopathy

If you’ve ever felt like the clinical picture was a little… muddled, this session will help you cut through the fog and sharpen your CDI insight.

Indiana ACDIS

Couldn’t Join Us Live? Get Instant Access to the Recording & Slides

This webinar is a focused deep dive into the essential work of trauma registrars, led by Michael Trelow, CSTR, CAISS, and special guest Jennifer King, CAISS. Jennifer is a trauma registry expert with 20+ years of experience across Level I–IV, pediatric, and burn centers.

Topic: The Trauma Registrar: Where Chaos Becomes Data

What You’ll Learn:

• How trauma registrars turn complex events into standardized, actionable data
• Why accurate registry data matters for verification, TQIP, and performance improvement
• Key components of abstraction: injury coding, E-codes, procedures, and mechanism of injury
• How standardized practices improve consistency and inter‑rater reliability
• The link between high‑quality data and better trauma care outcomes

Click here to download the PDF.

Couldn’t Attend? Get the Webinar Slides and Full Recording

Topic: Inside the Spine: Anatomy & Fracture Types

Date: March 25th

During this session, we will:

• Review the anatomy of the spine
• Discuss common and complex spinal vertebrae fractures
• Break down procedure codes used in spinal surgery repair

Click here to download the slides: Vertebral Spinal Injuries 1

Tip Card: Strengthening Revenue Cycle Performance Through Interim Staffing

Tip Card: Metrics to Consider for Strengthening Your UR Program

Tip Card: Front End Status Accuracy Practical UR Gatekeeping Strategies

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TIP CARD Discharge Planning

TIPS for the ODS Ambiguous Terms

Non-Analytic Class of Case Decision Guide (BASED ON STORE 2026)

Tip Card NAACCR Approved Abbreviations

Analytic Class of Case Decision Guide (BASED ON STORE 2026)

Nelson Score Tip Card

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Tip Card Hypertension

Tip Card Common Angioembolization and Ultrasound Procedures

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Common Operative Procedure Codes Tip Card

Le Fort Fracture Tip Card

Trauma Case Study Tip Card

Tip Card- TEAM Guide Transforming Episode Accountability Model

Tip Card- Heart Failure Classifications & Advanced HF Indicators (Print)

Tip Card Chronic Kidney Disease (CKD)

Missed Our webinar? Watch It Here!

This session focused on abdominal gunshot wounds, led by our Trauma Quality Director, Michael Trelow, with special guest surgeon Dr. Christine Toevs, who will share her clinical insights.

Session Highlights:

• Review the anatomy of the abdomen
• Discuss bullet trajectory
• Review procedure codes for abdominal surgery repair

A great opportunity for trauma registrars to sharpen skills and strengthen data accuracy!

Missed Our Webinar? Watch It Here!

Accurate ICD-10-PCS revision total knee arthroplasty coding is critical for compliance, reimbursement, and audit defense. However, revision knee cases, especially partial component exchanges, remain one of the most misunderstood and highly scrutinized areas in inpatient coding. Coders often struggle to determine whether a procedure should be reported using the Revision root operation or coded as a combination of Removal and Replacement.

This blog walks through a real-world clinical scenario involving a revision of a tibial component only. Using official ICD-10-PCS guidelines and best practices, we explain correct diagnosis selection, procedure coding, sequencing, and DRG impact. By the end, you will have a clear, practical framework to confidently code with similar encounters while reducing compliance risk.

1. Understanding the Clinical Scenario

A 79-year-old male is admitted for worsening pain and instability of a right total knee replacement that was originally performed six years ago. Imaging confirms mechanical loosening of the tibial component without evidence of infection.

During surgery:

• The orthopedic surgeon removes the failed tibial baseplate and polyethylene insert.
• The surgeon replaces them with a new modular tibial baseplate and insert.
• The femoral and patellar components remain intact.
• The operative note clearly documents: This is a tibial component-only revision A synthetic substitute was implanted.
• The postoperative course is uncomplicated Discharge occurs on postoperative day three.

2. Principal Diagnosis Selection

Mechanical Loosening as the Reason for Admission

The correct principal diagnosis is:

• T84.032A – Mechanical loosening of internal right knee prosthetic joint, initial encounter
  • Mechanical loosening prompted the admission and surgical intervention, meeting UHDDS requirements for principal diagnosis assignment.

3. Why the 7th Character “A” Matters

• The seventh character “A” (initial encounter) is appropriate because this admission represents active treatment of the complication. Even though the original knee replacement occurred years ago, this is the first encounter for treatment of the loosening.

4. ICD-10-PCS Procedure Coding Explained

Why This Is Not a “Revision” Root Operation

Although the surgeon uses the term “revision” in the operative note, ICD-10-PCS coding is based on what was done, not the procedure name. According to ICD-10-PCS guidelines, the Revision root operation is reserved for procedures that correct or adjust a device without removing it, such as repositioning or tightening.

In this case, the failed tibial component was completely removed and replaced.

Therefore, the correct approach is to code:

• Removal
• Replacement

5. Correct ICD-10-PCS Procedure Codes

Removal of Failed Tibial Component

• 0SPC0JZ – Removal of synthetic substitute from right knee joint, open approach
  • This code represents the complete removal of the failed tibial baseplate and insert. The device value “synthetic substitute” is supported by the operative note.

Replacement of New Tibial Component

• 0SRC0J9 – Replacement of synthetic substitute in right knee joint, tibial surface, cemented, open approach
  • This code captures the insertion of the new modular tibial baseplate and polyethylene insert. The qualifier specifying the tibial surface is essential because only one component of the knee joint was replaced.

Together, these two codes fully and accurately describe the procedure performed.

6. Why Other Coding Options Are Incorrect

• Coding Only Replacement: Fails to capture device removal and does not reflect the full scope of the procedure.
• Coding Only Removal: Under codes the encounter and may misassign DRG.
• Coding Osteoarthritis as Principal Diagnosis: Coding it as the principal diagnosis misrepresents medical necessity and creates compliance risk.

7. DRG Assignment and Reimbursement Impact

Correct DRG Grouping- When coded correctly, this encounter groups to:

• MS-DRG 470 – Major joint replacement or reattachment of lower extremity without major complication or comorbidity
  • Because the patient has no documented major complication or comorbidity and no infection, this is the appropriate DRG.

8. Why Accuracy Matters

Misclassifying a partial revision as a full joint replacement or failing to code device removal can trigger payer audits, recoupments, and compliance exposure. Revision arthroplasty cases are consistently high-risk for denials.

9. Compliance and Audit Takeaways

To support compliant ICD-10-PCS revision total knee arthroplasty coding, coders and auditors should always:

• Review the operative report in detail, not just the procedure title.
• Confirm which components were removed and replaced.
• Verify device type, fixation method (cemented versus uncemented), and material.
• Avoid using the Revision root operation unless the device was adjusted without removal.
• Query the provider if documentation is unclear or contradictory.

Additionally, documentation must clearly support medical necessities, such as mechanical loosening, instability, or device failure. If infection is present, coding and DRG assignment change significantly and may introduce a major complication or comorbidity.

10. Best Practices for Reducing Denials

• To reduce audit risk and denials in revision knee cases:
  • Educate providers on documenting component specificity.
  • Train coding staff on ICD-10-PCS root operation hierarchy.
  • Use internal audits to identify trends in under-coding or over-coding.
  • Align coding practices with official ICD-10-PCS guidelines and Coding Clinic advice.

For further guidance, refer to official resources from the Centers for Medicare & Medicaid Services and the American Hospital Association.

Conclusion

Accurate ICD-10-PCS coding for revision knee arthroplasty requires careful document review, strong understanding of root operations, and adherence to official guidelines. Coding partial knee revisions correctly helps protect reimbursement and reduces compliance and audit risk.

Need help reviewing complex orthopedic cases or training your coding team?

Contact us today and learn how to code ICD-10-PCS revision total knee arthroplasty correctly, avoid denials, and ensure compliance with this step-by-step guide.

Missed our recent webinar? You can now watch the full recording of “2026 NTDS Updates: Get Ready for the 2026 Dictionary.”

Led by our expert, Michael Trelow, this session walks you through the most important changes coming to the 2026 NTDS Dictionary.

In the recording, you’ll learn how to:

• Review retired data elements
• Identify new additions to the dictionary
• Understand updated descriptions and definitions
• Explore additional information provided for clarity
• Recognize associated edit checks and their implications

Whether you work in trauma registry, coding, data abstraction, or clinical workflow support, this recording will help you prepare for the upcoming updates with clarity and confidence.

After the presentation, participants will be able to:

• Discuss why Trauma Registry matters
• Detail the core functions of the Trauma Registry
• Show how the Performance Improvement cycle is supported by the Trauma Registry
• Discuss the real-world impact of Registry on PI

Date: January 28th

Time: 12:00 PM EST

It is the responsibility of the Trauma Registry Professional to be familiar with each hospital event to accurately identify and document the correct data points. Since hospital events can change from year to year, the Trauma Registry Professional must be adaptable to keep up with these changes.

Everyone has their own learning style. Some people grasp the NTDS document by reading it directly, while others find it more helpful to use an algorithm. Some key points to be aware of include learning how to correctly read the NTDS and reviewing the 2024 Hospital Event Algorithm flow chart. This is available for download from AKI TEST (facs.org). For the 2025 NTDS, the algorithms are integrated into the documentation.

When reviewing hospital events, extra effort is needed to identify specific conditions, such as Acute Kidney Injury. To comprehend what you’re examining, you might need to broaden your knowledge by learning about factors like what defines an eGFR.

Acute Kidney Injury Example:

Chronic Kidney Disease in Type 2 Diabetes | Kerendia® (finerenone) | Patient Site  (kerendia-us.com)

Understanding the language and structure of NTDS Hospital Event documentation is crucial for accurate data interpretation and reporting. The presence of “and/or” statements requires careful attention to ensure that the data is categorized correctly. Additionally, the flow of data within the algorithm can vary, highlighting the importance of a thorough review of each document. Familiarity with these nuances is essential for maintaining the integrity of the data and supporting effective patient care outcomes.

The American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) plays a crucial role in enhancing patient care by collecting data on hospital events. This data is instrumental in identifying facilities with lower incidence rates, which can then serve as benchmarks for others. By analyzing and adopting the strategies of these leading facilities, hospitals can work towards reducing their own event rates, ultimately improving patient outcomes and elevating the standard of trauma care.

As acute care case managers, we face numerous challenges in ensuring patients receive optimal care and effective discharge planning. This blog highlights these barriers and offers resolutions and advice to overcome them. Many challenges are interconnected, often compounding one another, making it critical to approach them with a strategic mindset.

5 Challenges in Case Management

In the complex healthcare landscape, case managers play a pivotal role in ensuring seamless patient care transitions, particularly as patients prepare for discharge from the hospital. These professionals juggle multiple responsibilities, including patient advocacy and resource management, to navigate the intricacies of care coordination.

Below, we explore five key challenges faced by case managers, specifically discharge planners in acute care settings, along with practical solutions to address them effectively.

1. Managing Complex Patient Needs with Limited Resources

Studies from the Journal of the American Medical Association reveal that nearly half of Medicare beneficiaries have at least three chronic conditions, making them more medically complex patients. Coordinating care for these patients requires collaboration among various specialists—physical therapists, hospitalists, dietitians, pharmacists, and behavioral health providers, among others.

Coupled with staffing shortages, budget constraints, and limited availability of post-acute services, case managers often struggle to deliver optimal care and discharge planning.

Resolution Advice:

• Identify high-risk patients early during their hospital stay to allocate resources effectively and strategize care plans.
• Conduct daily interdisciplinary rounds led by case managers to facilitate discharge planning and ensure comprehensive care.
• Collaborate with insurance providers’ case managers to enhance resource availability and ensure tailored discharge plans.
• Implement a complex case manager model, assigning experienced social workers or case managers to handle the most challenging cases.
• Educate case management teams on up-to-date guidelines and resources, empowering them to provide holistic, informed care.

2. Staffing Shortages and Heavy Caseloads

The American Association of Colleges of Nursing reported the largest drop in hospital-employed nurses in four decades from 2020 to 2021. These shortages lead to heavier caseloads for case managers and the need to onboard inexperienced staff, which can impact the quality and continuity of care.

Resolution Advice:

• Invest in recruitment and retention efforts, including mentorship programs, continuing education, and competitive compensation.
• Evaluate department structures to delegate non-clinical tasks where possible and streamline workflows for less complex cases.
• Use contract staff to cover gaps, ensuring experienced professionals are available to manage workloads effectively.
• Create a supportive team environment by celebrating small wins and fostering collaboration among team members.

3. Combating Work Fatigue

Case managers face high levels of stress due to the urgency and complexity of their roles. Constant interruptions, emotional labor, and the need to juggle priorities can lead to compassion fatigue and burnout.

Resolution Advice:

• Advocate for manageable caseloads and implement policies promoting work-life balance.
• Incorporate wellness programs and regular team debriefs to support mental health.
• Encourage regular breaks during shifts, even during busy times, to recharge and reduce stress.
• Optimize daily workflows to improve efficiency and reduce unnecessary strain.

4. Maintaining Regulatory Compliance

Case managers must ensure safe, effective discharges while adhering to strict regulatory requirements. Frequent changes in federal regulations, public health policies, and payer guidelines add to the complexity.

Resolution Advice:

• Stay informed about updates to Medicare, Medicaid, and Department of Health regulations through ongoing education and collaboration with quality teams.
• Use standardized documentation templates within EMRs to ensure thorough and compliant records.
• Conduct internal audits and use feedback to improve compliance practices.
• Simplify discharge instructions for patients and families, allowing time for questions to ensure understanding.

5. Effective Communication

Strong communication is essential for case managers to coordinate care effectively. Challenges include language barriers, cultural differences, and cognitive or emotional factors affecting patients and families.

Resolution Advice:

• Build trust with patients and families through consistent, empathetic communication.
• Use active listening techniques and avoid medical jargon when speaking with non-clinical audiences.
• Leverage multidisciplinary rounds to discuss discharge readiness, identify barriers, and align next steps.
• Provide clear, detailed handoffs to post-acute care providers, ensuring continuity of care.

Conclusion

Addressing challenges in case management requires interdisciplinary collaboration, adaptable workflows, and supportive technology to streamline communication and resource allocation. By prioritizing education, team support, and proactive problem-solving, case managers can improve outcomes for patients and families alike.

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/213908

https://www.aacnnursing.org/news-data/fact-sheets/nursing-shortage

Sometimes, the need for a massive transfusion in trauma patients is immediately apparent when they arrive in the emergency department trauma room. However, occasionally, a seemingly stable trauma patient may suddenly experience a drop in blood pressure, surprising the trauma team.

In the trauma data world, trauma registry professionals must come to know predictive tools that they must be able to document accurately. Such predictive tools would include Revised Trauma Score (RTS), Injury Severity Score (ISS), Glasgow Coma Scale (GCS). We are going to look at another predictive tool, Shock Index (SI) and break it down in what it is predicting.

Shock Index defined

Blood pressure and heart rate, when used individually, fail to accurately predict the severity of hypovolemia and shock in major trauma. The Shock Index (SI) is a straightforward calculation, derived by dividing the heart rate (HR) by the systolic blood pressure (SBP). This index can be quickly determined by Emergency Medical Services (EMS) and is valuable in assessing whether a patient needs transport to a trauma center. Additionally, in the Emergency Department triage area, SI helps identify patients at risk of hemorrhagic shock (HS) and the potential need for massive transfusions. It has been researched in patients who are either at risk of or experiencing shock due to various causes, including trauma, hemorrhage, myocardial infarction, pulmonary embolism, sepsis, and ruptured ectopic pregnancy.

Shock Index Levels

When it is broken down, the SI is looking at different levels of shock:

• No Shock: <0.6
• Mild Shock: ≥0.6 to <1.0
• Moderate Shock: ≥1.0 to <1.4
• Severe Shock: ≥1.4

Trauma Registry professionals should be able to understand all the predictive tools and help them know the SI and to not simply add it to the trauma registry should the trauma center be collecting the data but be able to know that the higher the SI, be looking for use of the massive transfusion policy (MTP) and find the type and number of units of different blood products being used.  Being able to link their critical thinking to potential performance improvement issues will make the trauma registry professional stand out and aid in better care for the trauma patient.

To read more about the SI, in 2010 the paper was presented at the 23rd Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma:

“Identifying Risk for Massive Transfusion in the Relatively Normotensive Patient: Utility of the Prehospital Shock Index”

*Vandromme, M. J., Griffin, R. L., Kerby, J. D., McGwin, G., Jr, Rue, L. W., 3rd, & Weinberg, J. A. (2011). Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index. The Journal of trauma, 70(2), 384–390. https://doi.org/10.1097/TA.0b013e3182095a0a

Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index – PubMed (nih.gov)

There has been considerable discussion in trauma centers about the optimal number of charts a Trauma Registry Professional should close daily. Some hospitals impose high demands, leading to rapid turnover among registrars. While tracking productivity is essential, it’s crucial to balance the number of charts closed daily with the complexity of data points that need to be abstracted and entered, along with other duties they are asked to perform.

The primary role of a Trauma Registry Professional involves abstracting data from electronic health records (EHR), accurately entering this information into the hospital’s trauma registry, and adhering to national coding standards from the National Trauma Data Standard (NTDS) and other relevant courses like AIS courses. Trauma Registry Professionals must be well-versed in the NTDS data dictionary and may also need to follow additional state-specific data requirements. Additionally, they might have to abstract certain local hospital data points that programs want to track.

According to the American College of Surgeons’ 2022 Standards Resources for the Optimal Care of the Injured Patient, each trauma center must have at least 0.5 FTE dedicated to the trauma registry per 200–300 annual patient entries. The count of entries is defined as all patients who meet NTDS inclusion criteria, and those patients who meet inclusion criteria for hospital, local, regional, and state purposes.” Trauma program managers and directors all know this requirement.

It is in the Additional Information that the ACS adds, “Trauma centers must take into account the additional tasks, beyond the abstraction and entry of patient data, that are assigned to the registrar. Processes such as report generation, data analysis, research assistance, and meeting various submission requirements will decrease the amount of time dedicated to the meticulous collection of patient data. Electronic downloads into the trauma registry also create additional tasks, as does ongoing data validation before data acceptance. Additional staff will be required to perform these tasks to ensure the integrity and quality of registry data, which are used for prevention, PIPS, and other essential aspects of the trauma program.”

Is the additional information being included when the trauma service decides to put a charts per day number in place? Let’s remember that not everyone works at the same pace. Are those differences accounted for? Chances are the current TPM has not hired or supervised all the registrars since the trauma service was started. The registrars that are in place now are often products of another TPM. Some registrars are fast in how they abstract charts, some are more deliberate, making sure they capture everything, and some decide to chase every rabbit that presents itself, thus making them a lot slower. Accuracy and consistency are paramount, and productivity should be tracked alongside accuracy. Data validation parameters should be in place, and registrars should be evaluated based on their experience and certifications. Balancing the number of charts closed daily with data accuracy is crucial.

The 2022 Standards, item 6.1, requires all trauma centers to have a written data quality plan with at least quarterly reviews. Data validation is key to maintaining quality data. Sharing data validation results in a shared folder allows the TPM and Trauma Surgeon to monitor staff accuracy continuously. To begin the process of productivity, you need to obtain some data from the trauma registry. Run several reports that would show average ISS, average Hospital Days, and average ICU days. This baseline will help to be a determining factor in the productivity process.

A simple way to track productivity is to use an Excel sheet that Trauma Registry Professionals can update weekly and submit to the TPM. The sheet should include the following information:

• Trauma Registry Number
• Medical Record Number
• Start Date
• End Time
• ICU Days
• Hospital Days
• Comments (Death, multiple OR, anything that impacts time in chart)

By tracking the number of charts completed and the time spent on each, registrars can gain a clear understanding of their productivity. Without this data, both the registrar and the TPM lack insight into actual performance levels. This tracking system allows registrars to monitor their improvement over time, fostering a sense of increased productivity.

Once you have this data, you can determine a reasonable daily chart closure target that your staff can manage accurately. Productivity and accuracy should be the primary goals for each registrar. This approach will also help you justify the need for additional staff to the administration, especially in response to any increases in trauma cases, as you’ll have a clear understanding of the workload capacity.

Resources for Optimal Care of the Injured Patient | ACS (facs.org)

“Leaders become great, not because of their power, but because of their ability to empower others.” – John Maxwell.

Cancer registry leaders are pivotal to the success of the oncology service line. Their role is not only to lead the registry team but also to manage registry data effectively. Strong leadership and management in cancer registries ultimately enhance the care received by each cancer patient and improve the quality of data that drives advancements in cancer care.

7 Principles for Success as a Cancer Registry Leader:

1. Data Integrity is Crucial
2. Standardization Enhances Collaboration
3. Data Utilization Drives Decisions
4. Visionary Leadership Propels the Team Forward
5. Feedback is Necessary
6. Emotional Intelligence Builds Strong Teams
7. Servant Leadership Supports Growth

Successful leaders share several traits regardless of industry:

• A clear vision and strategic direction.
• The ability to inspire and motivate their team.
• Demonstrating integrity and accountability in all actions.

These traits enhance team productivity and accuracy, increase morale and staff retention, and improve the accuracy and reliability of registry data.

Essential Leadership Skills for Cancer Registry Managers:

Communication

• Articulate goals and expectations.
• Foster open and honest dialogue with and among team members.
• Utilize multiple channels to communicate effectively across the organization.

Motivation and Engagement:

• Create a supportive environment that recognizes individual and team contributions.
• Encourage participation in decision-making to increase engagement.
• Set challenging yet attainable goals that motivate staff.

Problem-Solving:

• Approach problems systematically to identify root causes.
• Encourage creative solutions from team members.
• Use data-driven analysis to support decision-making.

Decision-Making:

• Gather comprehensive information before making decisions.
• Involve team members in the decision-making process to gain diverse perspectives.
• Be decisive and transparent about the reasons behind decisions.

Managing Cancer Registry Data

You are an interpreter, translator, and data manager as a cancer registry manager. When data is requested, take the time to understand what information is being sought. Your stakeholders, executives, and researchers may not fully articulate their needs. By understanding their goals, you can provide impactful data. Always provide a concise written summary that answers their questions and offers an interpretation of the data. Thoroughly review your data before sharing and address accuracy and workflow issues with your team.

3 Key Data Management Principles:

1. Data Integrity: Ensure the data’s accuracy, completeness, and reliability throughout its lifecycle. To maintain data quality, implement routine data validation checks, audit trails, and error-checking mechanisms.
2. Data Standardization: Ensure that data across different sources and systems is consistent and conforms to regulatory standards. Standardization ensures compatibility, improves data quality, and facilitates data sharing.
3. Data Usability: Design data systems and processes that make data accessible and usable for decision-making. Organize data clearly and logically and use tools that enhance data retrieval and analysis capabilities.

Empowering Your Team

As a leader in the Cancer Registry, it is imperative to empower your team. You are the department visionary, expert, and servant. Creating a specific cancer registry vision that aligns with your organization will inspire and motivate your team. Elevate your emotional intelligence and ensure you are building positive relationships. Communication and empathy are vital. Successful leaders are servants—your position is to serve your team.

Empower Your Team Through:

Training and Development:

• Provide ongoing education and training.
• Encourage professional growth.
• Utilize and create mentorship programs.

Delegation:

• Clearly define responsibilities and expectations.
• Match tasks with team members’ skills and career goals.
• Trust team members to perform, providing support but avoiding micromanagement.

Feedback and Recognition:

• Regularly provide constructive feedback to guide performance.
• Recognize and reward achievements in a timely and public manner.
• Foster a culture of appreciation and open feedback among the team.

3 Key People-Focused Leadership Strategies:

1. Empathetic Leadership: Cultivate the ability to understand, empathize, and be responsive to team members’ needs. This approach helps build trust and a supportive team environment.
2. Effective Communication: Develop open channels of communication. Ensure that information is disseminated promptly and transparently to facilitate informed decision-making and foster a positive and collaborative team culture.
3. Development and Empowerment: Focus on the continuous development of team members through training, mentorship, and opportunities for growth. Empower each team member by recognizing their strengths and providing professional development resources.

Feedback and Continuous Improvement

Effective leadership involves creating feedback loops where you can continuously give and receive feedback to improve. Avoid creating loops of only constructive criticism. Aggressive, demeaning, and highly critical leaders lead to stagnant teams, low productivity, low morale, and low retention.

Various methods can propel your team forward and improve data collection in the cancer registry. Implement one strategy at a time. Remember, we are not just capturing data; we are telling each patient’s cancer story in a statistically significant way that translates data into meaningful outcome improvements and programmatic developments.

Leading with excellence in the cancer registry involves managing data with precision and empowering your team to achieve their best. You can create a thriving, productive environment that improves cancer care and registry data quality by focusing on data integrity, standardization, usability, and people-focused leadership.

Embrace these principles and watch your team and the data they manage reach new heights of success.

Critical thinking skills are highly sought after today and are actively taught. With the constant influx of information from TV news and the Internet, it’s crucial to develop critical thinking skills to discern the truth. This is especially vital for Trauma Registry Professionals who handle abstracted information and processes within trauma services.

Critical thinking is defined as the “objective analysis and evaluation of an issue to form a judgment.” Key terms in this definition include objective analysis, evaluation, and judgment, which are essential components of the process. Critical thinking fosters effective problem-solving and creativity, and it underpins rational decision-making.

Below are realistic examples of how critical thinking resolved an issue for trauma registry professionals. The process of critical thinking involves five distinct phases.

5 Phases of Critical Thinking

1. Problem identification: clarifying the problem and determining the root causes between the current situation and the ideal outcome.
   • In the trauma service, a Trauma Registry Professional was tasked to find the missing EMS run sheets, often taking as long as 4 hours on Mondays.
   • EMS were not leaving the run sheets, causing delays in keeping concurrent.
2. Creative thinking: looking at the problem using outside the box thinking. Looking at possible solutions to the root causes through brainstorming, generating ideas.
   • The Trauma Registry Professional started brainstorming to figure out how to decrease the time a registrar must look for and request run sheets from EMS services.
   • Looking at if the trauma registry program can help.
3. Logical Analysis: testing assumptions, thoroughly evaluating options without bias, and ensure conclusions are not from incorrect beliefs and mistaken observation.
   • The registrars began to think outside the box. They reviewed EMS state regulations and found a regulation that said that EMS agencies must leave written documentation in the ED when dropping off the patient.
   • The registrars looked at how the trauma registry program can help.
4. Decision Making: criteria for deciding the path forward and done through team consensus that takes advantage of the knowledge and experience that assess risk and the chance of success and builds commitment to the proposed solution.
   • They found they can customize a single page report that they can send back to the EMS providers by secure email/fax within 24 hours of receiving the patient.
   • The report would be sent to the EMS agencies providing feedback for them. It would allow them to add a section for comments that could provide extra feedback like break out the Glasgow Coma Scale.
5. Coordination/Implementation: timeframes are set, assignments are assigned, and expectations are established.
   • The registrars worked with the PI nurses to create the report template that would pull the data from the registry and put it on the document for EMS feedback.
   • The Trauma Registry Professionals set a date when they would start to send out the reports initially, including the EMS regulation that reminds them to leave written documentation in the ED.

By employing critical thinking techniques, the trauma service was able to quickly obtain EMS trip sheets. Initially, when the trauma service began distributing custom reports, it took some time for EMS agencies to recognize their value. However, once they did, they eagerly incorporated the reports into their performance improvement processes.

Over time, EMS agencies began contacting the Trauma Registry Professionals within 24 hours of patient drop-off to inquire about their reports. If they hadn’t left a trip sheet, the registrar would inform them, and the EMS agency would promptly send it over within five minutes. This change significantly reduced the time the Trauma Registry Professional spent on Mondays calling for trip sheets, from up to four hours to just 30 minutes. As a result, the trauma service received the trip sheets immediately and could promptly deliver reports back to the EMS agencies, enhancing communication between the two parties.

While no one is perfect at critical thinking, consistent practice offers a significant advantage. Strong critical thinking skills enable us to understand ourselves and our opinions better, and to examine diverse perspectives without fear or bias. These skills are invaluable tools for proactively addressing problems in both personal and professional contexts.

First and foremost, data validation is an educational tool that sharpens the skills of the Trauma Registry Professional and in turn, develops better data for the trauma centers to use to improve patient care. Data validation highlights areas of weakness and motivates the registrar to pursue additional training, ensuring the accuracy of data points

There are many ways to do data validation on the trauma registry, so there are multiple tools that one can find to fit their trauma center needs. The main goal is to train the Trauma Registry Professionals to get the most accurate data from the EHR to the registry.

The Guidelines:

The National Trauma Data Standard (NTDS) serves as the essential data dictionary for all trauma registrars. It details all required data fields, providing definitions, element values, and additional information to ensure correct data entry. The NTDS includes a data source hierarchy guide, directing registrars to the appropriate documents for data retrieval. It also outlines associated edit checks, specifying that Level 1 and 2 edit checks must be corrected before data can be uploaded to the National Trauma Data Bank (NTDB). Statewide trauma data dictionaries, for states that track additional data, adhere to the same format as the NTDS.

Hospital-based data dictionaries are designed to indicate where to obtain data from the EHR. They should include an additional column specifying the exact location in the EHR to pull the data. This will assist new registrars in accurately entering data into the trauma registry.

According to the American College of Surgeons (ACS), up to 10% of the total charts per month must be validated. There are two schools in data validation of the trauma registry:

• 100% chart audit:
  • This is used for the new registrar. This will assist in finding out what areas they are weak in and in turn get them educated on those areas.
  • Some trauma centers still do 100% chart audits on all their records
• 20-25 data points:
  • Once the new registrar has shown proficiency in the 100% validations, you can then choose 20-25 data fields to perform the validation. You can choose what data fields to track, but it is important to cover the ones that help show the Probability of Survival.
    • Age
    • Mechanism
    • Blunt vs Penetrating
    • Revised Trauma Score
    • Injury Severity Score (ISS)
    • Based on 100%, you can add a percentage to take off for any missing or incorrect data that is found.
    • Inter-rater Reliability (IRR) is the percentage of accuracy the Trauma Registry Professional has obtained in the validation.

    If you select 20-25 data points and your registrars consistently achieves 100% accuracy, you can replace one of those data points with a new one to maintain engagement. Trauma Registry Professionals are aware of the data points being monitored, which helps ensure their integrity.

    One method to do data validation is that you have the data analyst and Trauma Registry Professional and PI RN, or other trauma registrar in the same room. The data analyst gives a registry number to the Trauma Registry Professional who in turn tells the PI RN the medical record number. After the PI RN opens the EHR, the analyst then goes through each data point that is being tracked. The PI RN finds it in the medical record, then answers the question and the Trauma registry Professional has to either acknowledge it as correct, or say it was missed in the registry. Then they can discuss where the registrar found the data.

    In data validation, you aim to identify patterns of missed or incorrect data. If a pattern is detected, you can guide the registrar to relevant courses to improve their understanding. Options include trauma registrar courses, ICD-10 courses, and AIS courses. Sharing validation scores on a shared drive allows the Trauma Program Manager and Trauma Medical Director to quickly review the inter-rater reliability (IRR) of the trauma registrars, ensuring high-quality reports from the registry.

    In conclusion there are many ways to validate a record for the Trauma Registry Professional. The main point is to be educational because no one is perfect. It should be a two-way street where the reviewer identifies the missing/incorrect data, presents it to the registrar and the registrar can show the reviewer where they got the data. All of this is done to help the registrar abstract and enter high quality data to help the hospitals improve the treatment of the injured patient.