Health Information Management

Q&A: CDI staff assigning DRGs

CDI Strategies, April 24, 2014

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Q: Over the years I have heard differing opinions regarding whether clinical or coding expertise should be weighed more during the concurrent record review process. I have been told many times to “think like a coder,” and “not get to clinical when you are looking at the chart.”

At my facility we designate the initial/queried MS-DRG as part of our concurrent process and we review all the final MS-DRGs to be sure that our queried diagnoses have been captured. A secondary benefit to doing this is to discuss differences in our views and to substantiate where we might have found something they didn’t see, or vice versa. It seems odd to me that one set of experience should be weighed more than another when we all work together and seem to bring different skill sets to the table.

A: In my opinion, the clinical thought process is just as important as coding awareness for CDI professionals. I view it as a collaborative process between CDI and coding staff so I think it is great that your organization allows for discussion and differing opinions.

Since the coder is the one who releases the record to billing, in some organizations their opinion does supersede that of CDI as they are able to release a record without consultation with CDI and/or prior to completion of CDI review (e.g., while there is an outstanding query) unless processes are in place to require reconciliation of disagreements between the two departments.

I think the management model of CDI has a huge impact on potential disparity among the “value” of CDI and coding opinions. My preference is for CDI and coding to be independent yet equal departments so both departments have an equal voice. Specifically, each department would have the same management structure, e.g., their own supervisor and/or manager, rather than reporting to the same manager. It is also important when implementing a CDI department that the expectation from the beginning is collaboration. The workflow process should support communication between the CDI and coding staff so the coders consider CDI reviews prior to releasing a bill and/or referring records back to CDI, as necessary, rather than coding the record independent of the CDI process.

Additionally, there should be a process for reconciliation that allows the views of both CDI and coding to be considered when disagreements occur such as use of the facility compliance officer or HIM director as a mediator.

In my opinion the role of CDI is to ensure the documentation in the health record is clear and precise so that anyone who reviews the record comes to the same conclusion. The “think like a coder” comment addresses the nurse’s tendency to assume the provider’s intent. While this helps when delivering clinical care it can be problematic in terms of coding. As such, nurses need to be sure the documentation is explicit rather than presumptive. Coding does not allow for assumptions, so although coders know “NA with an up arrow” is hypernatermia, they can’t code it as such unless the provider has made the diagnosis and it is supported as a reportable secondary diagnosis. Asking the CDI specialist to “think like a coder” is asking the CDI specialist to be sure the documentation supports the code assignment and if it doesn’t, to obtain clarification.

The goal of CDI should not be how many records they can “pre-code,” rather how can they make a record’s documentation explicit through provider education and the query process to ensure consistency in coding.  If two coders could come to different conclusions when coding the record then CDI has not done its job.

It sounds like your organization has a good process in place for working together with the coding staff. It is best practice to examine coder/CDI DRG assignment agreement rates. The focus of the CDI specialist is to look for what is missing in the medical record as the coders will still be coding the record.

Editor’s Note: CDI Education Director Cheryl Ericson, MS, RN, CCDS, CDIP, Associate Director, Education for ACDIS, AHIMA Approved ICD-10-CM/PCS Trainer, answered this question. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.This article was originally published on the ACDIS Blog.



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