Coders and clinicians seem to speak different languages. CDI specialists often serve as the translators between clinicians and coders, so it's important that all three groups work together.
Both coders and CDI specialists can query physicians when documentation:
- Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
- Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
- Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
- Provides a diagnosis without underlying clinical validation
- Is unclear for present-on-admission (POA) indicator assignment