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Tip: Connect your coding, clinical documentation improvement staffs by establishing clear roles

CDI Strategies, December 13, 2007

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One of the biggest challenges in implementing a successful clinical documentation improvement (CDI) program is getting HIM/coding staff and CDI staff to work together and minimize conflicts. An effective means of accomplishing this task is to invite coding staff to the same meetings that you use to educate your CDI staff, and take some time to define clear roles for each group, suggests Marion Kruse, MBA, RN, managing consultant for Navigant Consulting in Chicago, IL.

"When you do CDI education, get the coders in the same room as CDI so that they all understand that this is a team," Kruse says.

Make coding and CDI staff aware that they are in partnership together. The clinical documentation specialists' (CDS) role is to ensure accurate and complete physician documentation in a format that allows the coder to do his or her job.

Conversely, although clinical documentation staff typically assign a working DRG, it's the coding staff who has the ultimate responsibility for correct coding. "CDS' assign a DRG--they do not code--and there is a big difference," Kruse says. "Coding is a profession, you go to school; it's an art and it takes time to become an expert. Clinical documentation programs are not designed to turn CDS' into coders."

When a DRG conflict arises between coding and CDI, talk through the difference to find out why. Kruse says that coding staff occasionally can make mistakes or have a bad day, and other times CDI staff assign incorrect DRGs because they do not fully understand coding conventions.

"Either way, the CDS staff must understand that coders have the ultimate responsibility for the coding of the chart, and must defer to the coders' judgment and expertise," Kruse says. "CDS staff must approach these differences of opinion with an attitude of deference and work with the coders to determine what documentation is needed to assure the clinical and coding picture match."

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