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The Intersection of CDI and Coding: A Virtual Roundtable

“Joint education is so important. When there’s a conflict between CDI and coding, it stems from a lack of understanding the other’s perspective.”

– Leif Laframboise

Coding and CDI, both critically important to the success of our healthcare institutions, will continue to evolve in response to changes in technology, reimbursement, and workforce requirements. The relationship between CDIs and Coders is changing as Revenue Cycle Optimization requires a team approach that embraces all operational areas that impact revenue. We asked seven experts what they thought about the intersection of CDI and coding and what it means to them and their organization.

PARTICIPANTS

Leif Laframboise
RN, CCS, CDI professional with more than 20 years of healthcare experience who currently works for an academic medical center in the northeast

Nikki Miskowicz
RN, BSN, CCDS, manager of clinical documentation integrity at Stanford Children’s Health

Rayellen Kishbach
Director of Customer Success at MediRegs, a division of Wolters Kluwer Law & Business

Lisa A. Eramo
MA, moderator and freelance writer

Tammy Trombley
RHIT, CDIP, CCDS, Compliance Manager at HCTec, a coding, auditing, and CDI service provider

Trey La Charite
MD, FACP, SFHM, CCS, CCDS, Medical Director of Clinical Documentation Integrity and Coding at the University of Tennessee Medical Center

Mary Beth York
CCS, CCS-P, CIC, senior associate at Barry Libman, Inc., a coding and auditing company

MODERATOR: Healthcare reimbursement has changed so much in the last decade, moving from DRGs to MS-DRGs, ICD-9 to ICD-10, and fee-for-service to value-based payments. Have these changes affected how much CDI specialists need to know about coding? For example, do they need an in-depth knowledge of coding guidelines and classifications systems and/or a CCS credential? Or is baseline knowledge sufficient?

YORK: CDI specialists are clinical experts, but they also need to have a working knowledge of coding classifications, guidelines, and conventions. I believe the CCS credential is helpful because it exhibits mastery-level knowledge of coding, and it makes CDI specialists more marketable. The CCS provides the level of coding knowledge that CDI specialists must possess to perform their jobs effectively—especially as organizations face mounting audits. Documentation and coded data are paramount.

“One of the benefits of obtaining a CCS credential is that it can help CDI specialists understand inpatient procedure coding.”

-Rayellen Kishbach

KISHBACH: They need to be coding literate, but they also need to be mindful of the payment rules in each setting. They also need to understand how diagnosis codes drive quality metrics and reimbursement under alternative payment models. One of the benefits of obtaining a CCS credential is that it can help CDI specialists understand inpatient procedure coding. Also, most states have regulations that require billing auditors (including CDI specialists) to possess certain qualifications. This includes knowledge of the format and content of the medical record, clinical documentation standards, and coding and billing standards. The CCS credential helps demonstrate one’s knowledge of these topics and can help CDI specialists move into auditor positions.

“The CCS credential is really helpful for nurses moving into CDI because it provides such in-depth coding education. Understanding the coding guidelines helps CDI specialists know when not to query.”
-Tammy Trombley

TROMBLEY: I believe they need to know a lot about coding. Based on my experience, nearly all well-established CDI programs nationwide require CDI specialists to compute the baseline and working DRGs. Some CDI programs look for a coding credential, some look for an RN credential, and some look for both. It depends on the structure of the program. I don’t have the CCS credential, but I do have the RHIT credential along with 25 years of experience coding inpatient, outpatient, and radiology. With that said, I’m starting to think about obtaining the CCS credential because it would help me remain competitive in CDI. The CCS credential is really helpful for nurses moving into CDI because it provides such in-depth coding education. Understanding the coding guidelines helps CDI specialists know when not to query. For example, lab values show the platelet count to be 135. A CDI specialist is looking for diagnoses that impact quality measures for SOI and finds thrombocytopenia is a diagnosis on the list for a particular MS-DRG. The CDI specialist then needs to look for evidence in the record that the low platelet count can be supported as a secondary diagnosis according to UHDDS coding guidelines. The CDI specialist cannot find evidence of evaluation, treatment, diagnostic procedures, increasing the length of stay, or increasing nursing care or monitoring, so no query is needed.

“CDI specialists do need to know a lot about coding to perform their jobs effectively. Do they need to be a coder? No. But I do think the CCS credential is very beneficial.”
-Trey La Charite

LA CHARITE: CDI specialists do need to know a lot about coding to perform their jobs effectively. Do they need to be a coder? No. But I do think the CCS credential is very beneficial. When CDI specialists understand coding, they’re able to more nimbly understand issues within the chart. For example, if a patient has multiple rib fractures—but the CT scan says there’s a hemopneumothorax —it’s helpful to know that there’s a code-first note under rib fractures that says if there’s a hemopneumothorax, that goes first.

“People often ask me whether the CCDS or CCS is a better credential for CDI specialists. I always say CCS. That’s because CDI specialists pursuing the CCS credential will actually learn something new rather than validate their existing knowledge.”

-Leif Laframboise

LAFRAMBOISE: In the past, hospitals relied on clinically-experienced RNs and trained them in CDI. This training usually included a high-level explanation of coding concepts. Now, CDI specialists must have in-depth coding knowledge and be able to work collaboratively with coders. At our facility, CDI specialists perform a concurrent review before it goes to coding. If, after coding, it triggers a high-risk DRG (that is, high risk for denial or a symptom DRG), CDI performs a second-level review. If someone has a heart transplant without an MCC, that’s a problem. This back-and-forth process requires CDI specialists to possess a deeper understanding of coding. We also perform risk-adjusted mortality reviews, readmission reviews, and reviews for PSIs and HACs. Ultimately, the more CDI specialists know about coding, the more efficient the entire process so we can get the bill out the door.

People often ask me whether the CCDS or CCS is a better credential for CDI specialists. I always say CCS. That’s because CDI specialists pursuing the CCS credential will actually learn something new rather than validate their existing knowledge. With that said, the real value of any credential is in working toward the certification—not necessarily the credential itself. We always recommend that someone works toward the test, but even if they fail the test or don’t take it at all, they’re still ultimately better off for having done the preparation.

“I don’t think it would hurt CDI specialists to have the CCS credential, but I don’t think it’s imperative. If you’ve got a good coding team, then theoretically, you can work collaboratively with your coders when coding questions arise.”

-Nikki Miskowicz

MISKOWICZ: They need to understand coding and be able to identify the diagnoses that require additional specificity. Using the encoder is imperative. I don’t think they need to know every coding rule and guideline. They’re not paid to be coders. They’re paid to be nurses. When they remain clinical, they have credibility with providers. This helps with physician response rates and improves the overall quality of documentation. For example, a patient may have bacteremia, fever, and tachycardia, but that doesn’t necessarily equate to sepsis. Coders may query for sepsis regardless, but a nurse is more clinically savvy and knows when a sepsis query is and isn’t appropriate.

At our facility, we focus on quality. This means our nurses query when there’s a clinical reason to do so—not because it would necessarily impact coding or revenue. It’s about the integrity of the medical documentation. If the purpose of queries is to truly improve clinical care, then it shouldn’t matter whether there’s a coding impact. For example, sometimes providers document respiratory insufficiency. Although the coding guidelines state we may be able to capture respiratory failure, it doesn’t always make sense clinically to query. We want our nurses to remain clinical. When respiratory failure is a possibility, our CDI specialists work with service line physician champions to obtain clarification.

I don’t think it would hurt CDI specialists to have the CCS credential, but I don’t think it’s imperative. If you’ve got a good coding team, then theoretically, you can work collaboratively with your coders when coding questions arise. I think the CCDS credential provides CDI specialists with adequate coding education.

MODERATOR: Everyone seems to agree that CDI specialists need to know about coding. What’s the most important coding concept that CDI specialists need to know?

“Most CDI specialists are encoder dependent. They don’t realize that the encoder could lead them to the wrong diagnosis. Using the book can show them where the encoder might have taken them off track.”

-Mary Beth York

YORK: They need to understand the coding guidelines and be able to use the coding books. They also need to understand the coding conventions and classifications. Most CDI specialists are encoder dependent. They don’t realize that the encoder could lead them to the wrong diagnosis. Using the book can show them where the encoder might have taken them off track. Understanding the classifications and conventions can also help them avoid unnecessary queries. For example, they could query for something that has no relevance or that doesn’t change the code assignment because it’s a non-essential modifier. The index provides essential modifier sub-terms under the main term that make a difference in the code assignment.

MISKOWITZ: They need to be able to identify the principal diagnosis, principal procedure, and any secondary diagnoses that could impact the DRG. They also need to understand diagnoses that affect severity of illness, risk of mortality, and quality metrics. This isn’t a coding concept per say, but they also need a good relationship with the coding team so when they do have questions, they can reach out to the coders.

“Being an effective CDI specialist is all about being able to identify and proactively mitigate risk using available resources.”

-Rayellen Kishbach

KISHBACH: First, CDI specialists need to know how to access their hospital’s PEPPER to identify risk based on their volume of certain DRGs. High-volume DRGs are often the target of audits. They also need to know what their RAC, MAC, and state OIG are investigating. Being an effective CDI specialist is all about being able to identify and proactively mitigate risk using available resources.

Second, they need to be able to go beyond the coding guidelines to understand payer-specific instructions for coding, billing, medical necessity, prior authorization, and benefits. This information comes from literally hundreds of sources that can be updated weekly. A big challenge for CDI specialists is keeping up with all of this information—knowing what they can ignore and what they need to focus on in terms of the deluge of information that’s coming in every day. What matters for CDI? What regulations have a potential documentation impact? And if they’re auditing retrospectively, they need to be able to access payer-specific guidelines in effect at the time of claim submission. This could require access to information from several years ago. Researching archived information can be challenging because the Internet tends to include only the most updated policies.

Third, they need to be able to make the connection between documentation errors or omissions and court cases, RAC audits, corporate integrity agreements, and physician penalties. Physicians pay attention to dollars and professional risk because they want to be well-regarded in their field. When they hear about other doctors who have been sanctioned, they pay attention.

Finally, they need to understand HCC coding because these codes drive Medicare Advantage dollars and other risk-adjusted payments. They need to be able to identify HCC diagnoses and ensure that physicians update these diagnoses in the medical record annually.

TROMBLEY: They need to be able to identify the principal diagnosis that drives the DRG. Once you know the correct DRG, you also know what CCs and MCCs, if any, matter for that DRG. Sometimes assigning the principal diagnosis is tough because patients are often admitted with multiple conditions (e.g., syncope, AKI, and dehydration). It’s easy to get lost in the clinical picture without focusing on what matters most for coding purposes.

“When I first started in CDI, CDI specialists had the book, but nobody knew how to use it.”

-Trey La Charite

LA CHARITE: They need to know how to use the code book. When I first started in CDI, CDI specialists had the book, but nobody knew how to use it. But if you know how to work your way through the book, you can usually answer any questions that come up. You don’t get this type of training with the CCDS credential.

MODERATOR: What’s the biggest challenge you’ve encountered in the last week?

TROMBLEY: I’m in the process of learning more about E/M coding and CPT guidelines so I can help train and audit other outpatient CDI specialists. CDI has traditionally focused on inpatient only, so E/M coding isn’t something with which many CDI specialists have experience.

“Provider documentation is the biggest challenge—getting providers to buy into CDI and provide quality documentation. This was the same challenge ten years ago when I started in the profession.”

-Trey La Charite

LA CHARITE: Provider documentation is the biggest challenge—getting providers to buy into CDI and provide quality documentation. This was the same challenge ten years ago when I started in the profession. I don’t think this is something that CDI specialists can fix unfortunately. It’s more of an administration problem. Administrators must talk to the medical staff and convey the importance of documentation.

LAFRAMBOISE: Keeping up with the pace of change is the biggest challenge. RNs come from a profession that changes slowly. The human body doesn’t change. But CDI changes so rapidly. We have an opportunity to impact value-based payments and our ranking in U.S. News & World Report—so we keep pushing the envelope to do these things.

MODERATOR: Can you provide a recent case example that required additional research and/or education for your CDI staff?

“I had to research an argon plasma coagulation procedure for bleeding arterial venous malformation. A CDI specialist and coder both coded it as ‘control’ of the bleed.”

-Tammy Trombley

TROMBLEY: This happens all the time especially when you’re auditing. For example, I had to research an argon plasma coagulation procedure for bleeding arterial venous malformation. A CDI specialist and coder both coded it as ‘control’ of the bleed. But then I remembered there was an updated Coding Clinic about hemorrhage control stating that if the control moves to a more definitive root operation, you should assign the other more definitive root operation. In this case, it was destruction. Another example is COPD exacerbation with influenza and pneumonia. Influenza is the principal diagnosis based on sequencing. However, some CDI specialists will put the pneumonia first. Spinal procedures are also tough, and OB coding sometimes requires additional research because there are chapter-specific guidelines.

LAFRAMBOISE: We sometimes need to provide education about cases that move from outpatient to observation to inpatient. What qualifies as the principal diagnosis for admission? Another topic is symptom coding. For example, can we code weakness as a secondary diagnosis that holds value under risk-adjustment if the patient also has anemia?

MODERATOR: What are the cases you or your staff struggle with most, and why? What’s typically missing from the documentation?

TROMBLEY: Sometimes it’s not about what’s lacking—it’s about what’s already there. Some physicians copy and paste diagnoses without updating the assessment and plan. CDI specialists can get lost in conflicting documentation. CDI teams, IT, and physicians all need to work together to solve this problem.

“Acute encephalopathy cases can be challenging because providers are sometimes too lenient with this term.”

-Trey La Charite

LA CHARITE: Acute encephalopathy cases can be challenging because providers are sometimes too lenient with this term. They document it when there’s only a slight change in a patient’s mental status. In terms of documentation omissions, we sometimes see cases where the patient met criteria for sepsis or renal failure, but the physician didn’t document it.

“There’s never a day when sepsis isn’t a big concern.”

-Leif Laframboise

LAFRAMBOISE: There’s never a day when sepsis isn’t a big concern. There are state programs that penalize hospitals for not recognizing sepsis as early as possible and treating it as aggressively as possible. When we do second-level reviews for UTIs and simple pneumonias, sepsis is often found as well. It’s missed on the first-level review by the CDI specialist. The interesting thing is that if you read the records, physicians treat the sepsis correctly (meeting the three- and six-hour bundle), but they forget to write the word sepsis. Other cases where documentation is lacking include acute blood loss anemia, encephalopathy, complex pneumonia, and malnutrition. Thirty-five percent of patients in the acute clinical setting have some degree of malnutrition, and hospitals don’t pick it up nearly as frequently. Malnutrition is such an important driver of mortality, so we don’t want to miss that. Another area of concern is complication coding. When is it truly a complication of a surgery versus an expected post-operative event? The language can be so nuanced.

MODERATOR: What do you think would help CDI specialists understand coding?

YORK: Education. CDI specialists don’t know what they don’t know. Once they start learning about coding conventions, guidelines, and classification systems, they better understand what to query, and more importantly, why.

MISKOWITZ: We use internal resources (coders) to train our CDI specialists. More specifically, we have monthly coder-CDI meetings. CDI specialists provide clinical information about a specific topic, and then a coder gives coding examples. Then there’s a Q&A.

TROMBLEY: Obtain the CCS credential. Self-paced online learning modules can also help CDI specialists learn more about coding.

“Anytime there’s a query mistake or error, we bring it to our CDI specialists’ attention. With that said, most denials we get are clinical validation denials.”

-Trey La Charite

LA CHARITE: Anytime there’s a query mistake or error, we bring it to our CDI specialists’ attention. With that said, most denials we get are clinical validation denials. They’re not coding related. We also hire an external vendor to help provide basic coding training to new CDI specialists. It’s a four- to six-week class of in-depth training, but it’s not enough preparation for the CCS or CPC exam. Both of these coding credentials aren’t easy to obtain, and we don’t require them for our CDI staff. The training touches on adult medicine and how it relates to each major diagnostic category and the coding guidelines. It’s also tailored to our organization and the types of cases we see. CDI specialists working in the outpatient setting also receive fairly in-depth risk adjustment training

LAFRAMBOISE: More coding training. They simply need to train more. Getting the CCS credential is the best way to do that.

MODERATOR: Is joint education beneficial for coders and CDI specialists? If so, what topics could benefit both roles?

YORK: I don’t recommend joint education because coding and CDI are two distinct functions. You need to tailor content accordingly.

MISKOWITZ: I think joint education is a good idea. We provide our coders and CDI specialists with access to the same online learning modules that focus on major diagnostic categories, including conditions and applicable codes within those categories.

TROMBLEY: We provide joint education about annual coding updates, new coding clinics, and clinical indicators for query opportunities.

LA CHARITE: We provide a joint two-hour educational program quarterly. The first hour is spent reviewing problematic diagnoses and procedures from a medical perspective, and the second hour is spent reviewing coding mistakes that external auditors found.

LAFRAMBOISE: We’ve turned all of our education into joint sessions. Coders can attend CDI sessions to learn more about clinical topics and vice versa. It’s a great opportunity to share information and collaborate. Previous topics include respiratory failure, encephalopathy, AKI, hemodynamics, shock, and sepsis. We focus on the clinical indicators, and what must be documented for accurate code assignment. We also touch on relevant guidelines and coding clinics.

“Joint education is so important. When there’s a conflict between CDI and coding, it stems from a lack of understanding the other’s perspective.”

-Leif Laframboise

Joint education is so important. When there’s a conflict between CDI and coding, it stems from a lack of understanding the other’s perspective. Joint education can help staff understand that even though we’re all reading the same documentation, CDI looks through a clinical lens while coding looks through a guidelines/conventions lens. The interpretations can be very different because of this.

MODERATOR: What are 2-3 strategies that can help build a cooperative environment in which CDI specialists and coders work together to ensure data integrity?

MISKOWITZ: Discuss DRG mismatches. This is an opportune time to share knowledge. Coders can share information about coding that CDI specialists may not have been aware of and vice versa.

“I recently worked with a hospital where everyone was so nice when working through DRG mismatches. You don’t see this too often.”

-Tammy Trombley

TROMBLEY: Ask a CDI specialist to shadow a coder for half a day and vice versa. Also, managers need to reiterate the importance of respectful and polite communications between coders and CDI specialists. I recently worked with a hospital where everyone was so nice when working through DRG mismatches. You don’t see this too often. When coders and CDI specialists can’t agree on a mismatch, create a process where there’s another layer or review and reconciliation. Ask a supervisor or CDI coordinator to serve in this role—someone who has more experience.

“You can’t have CDI running out of finance and coding running out of HIM. That’s too siloed.”

-Trey La Charite

LACHARITE: CDI and coding need to be in the same department with the same set of leaders so everyone is on the same page. You can’t have CDI running out of finance and coding running out of HIM. That’s too siloed. You also need a process to resolve DRG mismatches. At our facility, when CDI finishes reviewing the chart, they assign a preliminary DRG. Then the coder assigns a final DRG. If there’s a mismatch, the two are required to talk about it. The nice thing about that is the CDI nurse learns from the coder and vice versa. That’s extremely productive. Mismatches occur weekly and can often be resolved after a conversation. If it can’t be resolved, we have an escalation process so a coding quality auditor reviews the case and makes the final decision. CDI specialists may not realize there’s a code first, code also, or combination code that takes precedence.

LAFRAMBOISE: Set up a buddy system. At our facility, each CDI specialist is assigned to a coder. If the CDI specialist has a question about coding, they call their coding buddy for clarification.

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