Health Information Management

Defining the goal of the CDI department

HIM-HIPAA Insider, April 14, 2014

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In an ideal world, all coders and CDI specialists would get along well and work together with minimal conflict. No one is going to agree all of the time, nor should they. A healthy, respectful dialogue can lead to a better understanding of the patient's clinical condition and result in more accurately coded records.

In the real world, that doesn't always happen. In some cases, the coders and CDI specialists can get into a turf war over who is supposed to do what and who has the final say. How an organization introduced its CDI program can also factor into how well CDI and coding work together. "If you had a job and you thought you did it well, and you heard that some nurses were coming in to potentially take over your job, that would be intimidating," says Cheryl Ericson, MS, RN, CCDS, CDIP, CDI education director for HCPro, a division of BLR in Danvers, Mass. "If those nurses act like they know the job better than you, it would be frustrating and could lead to resentment."

Problems can arise when CDI specialists think their job is to pre-code the record, Ericson says. "Coders know how to code and they do it very well. They don't want the CDIs to pre-code. They want CDI to be addressing ambiguities and conflicts in the documentation."

CDI specialists should be looking at documentation in real time while the patient is in the hospital and making sure the documentation can translate into codable language, says Candice Koldyke, RHIA, CCS, C-CDI, process improvement consultant, Training & Development Department at St. Vincent Health in Indianapolis.

Continue reading "Defining the goal of the CDI department" on the HCPro website. Subscribers to Briefings on Coding Compliance Strategies have free access to this article in the April issue.


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