Health Information Management

Associate Director's Note: CDI and coder collaborate closely, poll shows

CDI Strategies, September 3, 2015

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Collaboration between CDI and coding professionals used to be a contentious issue. Coders, who long held responsibility for physician queries, saw CDI implementation as an infringement on their typical duties and scoffed at the lack of coding knowledge clinically-minded CDI professionals seemed to have.

CDI nurses, on the other hand, found the strict rules governing query and coding practices limiting, confusing, even bewildering. Often the two teams were at loggerheads. At worst, managers kept the teams separate entirely, limiting CDI specialists contact with coding team members often due to productivity concerns. 

Yet, such 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.

ACDIS and its advisory board has frequently touted the vital role of open communication with, and involvement of, various healthcare professionals in CDI efforts. It supports the experience and expertise of various professionals in the role, as well, from coders to nurses to nurse practioners to physicians.

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. For additional information read:

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