Health Information Management

Q&A: Coming to terms with the clinical/coding language disconnect

CDI Strategies, February 2, 2012

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Q:  I am fairly new to CDI and I have a nursing background. I’m trying to understand how the coding and DRG systems work. But when I look up a diagnosis in the DRG Expert in the alphabetic index to diseases it is not listed as I would expect it to be.

Take for example, bradycardia. It is not listed under that term or arrhythmia.  Yet, it is listed under cardiac arrhythmia. How about anorexia, as another example? The only listing is anorexia nervosa—not unspecified.
 
I also find it ironic that I cannot infer what a physician is stating (it has to be documented precisely) but when I have to look up a term I have to guess its meaning. Do you have any advice for me?
 
A: Your frustration is very common among new CDI specialists. The publishers of the DRG Expert did not include the same type of Index to Diseases that you would find in Volume I of an ICD-9 code book—probably to save space. The Index to Diseases alone in my code book is more than 380 pages.
 
This is one reason that when I teach the CDI BootCamp I mention so many diagnoses during the class’ review of Medicare Severity Diagnosis-related groups (MS-DRGs) in a major diagnostic category (MDC) and either have participants highlight certain terms or write them in. Believe it or not, I too had exactly the same issues you are having.
 
Every CDI team should also have a coding book in their department to use as a reference (ask your facility HIM department if they have an old one you can have), especially if you do not have access to an encoder (coding and reimbursement software), which would let you look up whatever you wanted—however, even that has limitations, because search terms often use “coding language” rather than the everyday language of clinicians.
 
As far as your comment regarding the irony of the situation, all I can say is it is the reason CDI specialist profession exists. We are the “translators” or “interpreters” to ensure that the clinical language matches the coding language. Regardless of whether you are an experienced coder or an experienced nurse, acquiring the skills to understand both of these languages, along with the ability to translate from one to the other, is what makes us, as CDI professionals, unique.
 
Since I have a nursing background, I just want to share that my very first DRG Expert was covered from end to end with handwritten notes, stickies, and slips of paper. I used this book for three years, copying my info into each new edition until I was granted encoder access. Every time I asked a coder where to find something I wrote it in the book—especially those diagnoses that had really strange “code” descriptions.
 
There can be a long learning curve to this position, so don’t worry. While some people catch on quickly, for most it may take up to six months before that proverbial light bulb finally goes on. Don’t get discouraged. Before you know it, you will find yourself sitting in traffic, converting license plate numbers into DRGs or diagnosis codes.
 
Editor’s Note: This question was answered by Lynne Spryszak, RN, CCDS, CPC-A, AHIMA-Approved ICD-10 CM/PCS Trainer, CDI Education Director for HCPro Inc., in Danvers, MA, answered this question. It originally published on the ACDIS Blog. Contact her at lspryszak@hcpro.com.



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