Health Information Management

CDI and coders collaborate closely, poll shows

HIM-HIPAA Insider, September 21, 2015

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Collaboration between CDI and coding professionals used to be a contentious issue. Yet, collaboration between these two professionals represents one of the most essential elements of a successful CDI program. One may argue that CDI programs themselves took root as a method of assisting coding departments by obtaining the clearest documentation in the medical record before the record even arrived.

So it’s heartening to see in the current ACDIS poll that 67% of nearly 300 respondents hold regular meetings where both CDI and coding staff sit at the table together. Unfortunately, on the other side of the coin, 23% indicated they meet annually or not at all.

Although CDI programs may have different focal areas (CC/MCC capture rates, DRG clarifications, SOI/ROM improvement, and so on), at its most basic CDI programs serve as interpreters, translators between the clinical language of physician speak and the nuanced vernacular of various code sets. Effective translation requires an understanding of the various dialects spoken and this, in turn, requires frequent interaction and discussion amongst all parties.

Daily interaction allows coders to tap their counterparts’ clinical acumen and perhaps avoid the need for a retrospective query or better sequence a principal diagnosis. Daily chats may help with CDI/coding DRG validation and increase the CDI staff’s awareness of compliant query practices and changes in coding governance.

At weekly, more structured, meetings team members can workshop difficult medical records and review reasons for any DRG mismatches. At monthly events, leadership can share CDI and coding metrics with the team, highlight successes, and point out shifts in CDI program focus areas that might affect the coding staff and overall facility efforts.

If your program numbers itself among the poll’s 67% we applaud your efforts. If, instead, it falls within the 23% which rarely interacts with coding/HIM, we encourage you to take another look at the possible benefits.

Editor’s note: This article is excerpted from the latest CDI Strategies Associate Director’s Note.

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