Health Information Management

Tip: Elevate coder's role in concurrent reviews

CDI Strategies, April 2, 2009

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Everyone knows that an immense amount of teamwork is necessary for a CDI program to truly be successful. Physicians and facility administration need to be supportive, of course, but the primary CDI stakeholders—i.e., nurses/CDI specialists and coders—need to work together.

Many CDI programs use nurses as their primary concurrent reviewers, the argument being that a nurses speak “clinical-ease,” i.e., the physician language. However, without the specific knowledge of coding guidelines, such clinical knowledge may muddy the already murky waters of documentation. “It is helpful if nurses who perform concurrent reviews have experience in ICD-9-CM coding guidelines and knowledge of MS-DRG assignment,” says Mary Mills, RHIT, CCS, president of Documentation Solutions, LLC, in Dearborn Heights, MI

Inviting an assigned coder to attend morning meetings with hospitalists and CDI staff is another good option, particularly for smaller hospitals, Mills says. That way the CDI program can discuss admissions that occurred during the night or follow up on patients who are already in house. While this may not be ideal in every situation, such an arrangement allows the coders to interact with the clinical staff members, to participate in the documentation dialogue, and essentially “get in front” of the clinical staff.



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