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Attn CDI Specialists: Coding as a “Second Language”


by Mary Beth York, CCS, CCS-P, CIC

It is helpful sometimes to think of coding as a language. The language consists of the ICD-10-CM, ICD-10-PCS, and CPT code sets primarily. This language of coding has rules, similar to grammar, that govern how it is used and applied. It also has inconsistencies and internal conflicts, much like our spoken languages, that make the use and application of the coding systems both challenging and interesting.

Clinical Documentation Improvement Specialists (CDIS) are often clinicians and well versed in the language of medicine. I recommend that CDI Specialists need also to master the language of coding, in order to be truly effective in their job.

Coding is used to translate medical documentation (the language of medicine) into medical data (the language of coding) for both statistical and reimbursement purposes. By knowing the rules of these complex classification systems, the conventions which govern the systems, and the guidelines which determine how to use the codes, CDI Specialists can focus their efforts on creating documentation that will translate more easily and completely into appropriate codes for that record.

Similar to learning a second spoken language, for CDI Specialists who make the effort to truly master the coding systems, their understanding of documentation will be enriched and deepened. Coding skills will make them better CDI Specialists.

One way to achieve mastery-level coding skills is to prepare for the Certified Coding Specialist coding credential from AHIMA. The CCS coding credential is held primarily by hospital coders but is also valuable to anyone who needs to demonstrate mastery of the coding systems. The process of preparing for the CCS ensures one attains in-depth knowledge of the coding systems. Mastery-level knowledge of coding can help CDI Specialists to do their job more efficiently.

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About the Author

Mary Beth York, CCS, CCS-P, CIC
Mary Beth York has over twenty year's experience in coding, auditing and documentation improvement for hospitals ranging from community to teaching hospitals as well as physician group practices. Mary Beth is the author of Libman Education's highly successful CCS Exam Prep course, as well as Libman Education's highly successful CCA Exam Review course. 

3 thoughts on “Attn CDI Specialists: Coding as a “Second Language”

  1. Tyrone Mangum - May 8, 2018 at 10:48 pm

    How can individuals who are from a coding background doing CDI functions aspire to be better CDI proffessions?

    • Libman Education - May 31, 2018 at 7:50 pm

      Hi Tyrone,
      Thanks for the question. Have you considered earning your Certified Coding Specialist (CCS) certification? The more you know about coding, the more effective and efficient your documentation efforts will be. Libman Education offers CCS courses that can help you with this: https://libmaneducation.com/product-category/exam-prep/ccs-exam-prep/

      Best wishes for your growth as a CDI professional! — Libman Education

    • John - July 21, 2019 at 12:43 am

      The fact is AHIMA dropped the ball a long time ago. Coding is moving to CDI/Nursing. I got a CCS, CDIP, and soon a CRC certifications and although it has helped me tremendously in the coding process it’s not recognized by my hospital employer.