Health Information Management

HIM, CDI programs require 'TEAM' effort

JustCoding News: Inpatient, March 31, 2010

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by Lynne Spryszak, RN, CCDS, CPC-A

There is a poster that I’ve seen in several hospital departments around the country: “TEAM—Together Everyone Achieves More.”

The problem, as I see it, is that developing a team takes more than just a poster. It takes collaboration, patience, and trust. These three qualities are often in short supply when facilities drive coders’ and clinical documentation improvement (CDI) specialists’ assignments and workloads by productivity standards and financial considerations rather than accurate data and compliance.

Coders are accountable for every code they assign. They have to use the correct code, and the record must support the condition for the code they assigned. When they review a record that contains nonspecific terminology, vague wording, or inconsistencies, they may feel that the CDI specialist has not done his or her job. After all, many new CDI programs are “sold” to coding staff members with the premise that it will reduce or eliminate the need for retrospective queries, thus making coders’ jobs easier.

On the other hand, many CDI program leaders tell documentation specialists to focus on reviewing those records that have “opportunity” (i.e., those with the potential for increasing revenue, minimizing audit risk, or improving documentation in a specific service line).

Very seldom does facility leadership instruct CDI specialists to focus on overall compliant documentation, regardless of the reimbursement or data quality. This differing set of expectations divides the team. It makes getting the two groups to work together a momentous challenge.

Following is a suggested blueprint for fostering increased collaboration among CDI specialists and coding staff members.

Step 1: Define expectations
Building a strong clinical documentation specialist (CDS)/coding team needs to start with defining expectations. The expectations should be clear so that success is measurable. One example of a CDI program expectation might be that all physician queries will be resolved prior to final coding and billing. This type of expectation ensures that the coders’ goals are met (i.e., questionable documentation will be clarified prior to coding).

Defining the process for accomplishing this goal depends upon input and agreement from the executive team as well as the coders and documentation specialists. Coders need to know that holding a record from final billing will not result in criticism. Documentation specialists need to know that the executive team supports their work in identifying opportunities to clarify documentation as a valuable component of accurate data reporting.

Step 2: Meet regularly
Both groups should have the opportunity to meet on a scheduled basis. It may be daily, weekly, or monthly, depending on the length the documentation program has been in place, but management should support this time and not view it as time away from work, but rather as an integral part of the documentation improvement process.

Teams need to interact to be successful. Regularly scheduled meeting times allow team members to collaborate on ongoing documentation initiatives, take part in ongoing education, discuss issues, and develop solutions.

Today, many coders work off-site and communicate primarily via e-mail or telephone. CDI specialists often have limited access to coders due to administratively imposed restrictions. Lack of ongoing communication limits the team’s problem-solving ability.

While it is inefficient for coders to receive random calls throughout their day, having a designated process for communicating questions and answers benefits both groups without affecting the productivity of either.

This process may include designating one person, for example a DRG analyst, to respond to CDS questions during a specific time frame, either via e-mail or telephone. This may take place in the morning or the afternoon, depending on work schedules.

The coders need assurance that CDI specialists will consider records held for additional documentation a priority. If the documentation specialist “owns” a query until he or she receives a response from a physician, coders and documentation specialists should develop a defined process for obtaining a response with input and support from the program leaders and, when possible, the facility’s executive team.

Step 3: Implement conflict resolution processes
When conflict arises between a coder and documentation specialist, the team should have a mechanism for conflict resolution. Is it a question of whether the record supports a diagnosis or whether the documentation is sufficient for code assignment? The CDI team should consider designating an authorial staff member, whose determination everyone will consider final. For clinical issues this may be a physician advisor or champion, or the chief medical officer. If it’s a coding issue it may be the HIM director.

At all costs, avoid procedures that eliminate one of the parties from the process. Consider the following examples:

  • “I asked another coder and he/she agreed with me so I dropped the bill.”
  • “I reviewed the record and the query was answered so you have to code it.”

When the same situation arises frequently, it indicates problems with the current process and additional team discussion or process revision may be necessary to meet everyone’s goals.

A common problematic situation is when CDI team members report to different levels of administration. HIM often reports to finance, and the CDI specialists often report to case management, who then reports to nursing or quality. If the directors of these groups do not have a united approach, it will be difficult to resolve conflict between the coders and documentation specialists.

To address this problem, consider having the CDI team report up through the same administrator as the coders or implement an executive steering committee that is responsible for defining goals and expectations.

Step 4: Have patience and persevere
Patience and trust are qualities that are the hardest for teams to achieve and the easiest to lose. Having well-defined program expectations and ensuring that all team members adhere to agreed-upon processes and procedures will build trust.

All team members need to exercise patience. New documentation improvement programs experience growing pains and one of these is the long learning curve for new documentation specialists. Even a good didactic program doesn’t address every documentation issue; the CDI specialists learn on the job, and patient feedback from the coders will speed this process.

Effective teams are not built overnight, but with patience, collaboration, and trust, everyone can achieve the desired goal of obtaining the most accurate information for inclusion in the patient’s medical record.

Editor’s Note: This story was originally published in the April issue of the Association of Clinical Documentation Specialists (ACDIS) quarterly journal. Lynne Spryszak, RN, CCDS, CPC-A, is CDI education director for HCPro, Inc., in Marblehead MA. Her areas of expertise include clinical documentation and coding compliance, quality improvement, physician education, leadership and program development. E-mail your questions to her at

In addition to open registration classes, ACDIS also offers the Clinical Documentation Improvement Boot Camp as a cost-effective on-site program for organizations that have a number of employees who need training. To explore the possibility of bringing Lynne Spryszak on-site for a CDI Boot Camp or to discuss other training programs, please contact us at 800-780-0584 or e-mail

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