by Mary Beth York, CCS, CCS-P, CIC
Having worked with hundreds of coders to achieve their Certified Coding Specialist (CCS) coding credential, I am increasingly approached by individual, clinically-skilled, Clinical Documentation Improvement Specialists (CDIS) to assist with mastering the intricacies of inpatient and outpatient coding as they prepare to earn their CCS coding credential. I have also worked with entire CDI teams — HIM directors with responsibility for the CDI function are often the first to see the value in increased coding proficiency among their CDIS.
CDIS are key team members of any hospital’s revenue cycle operation. CDIS ensure that the provider’s documentation captures all clinical information completely and accurately. The documentation must then be translated into codes in accordance with the conventions of the classification and the Official Guidelines for Coding and Reporting, in order to be processed for data and billing purposes.
There are several reasons why a CDIS should consider earning their CCS:
1. The process of preparing for the CCS requires in-depth review of ICD-10-CM, ICD-10-PCS, and CPT code sets. This in-depth knowledge of coding helps CDIS to efficiently evaluate existing documentation for improvement opportunities that will have the greatest impact on coding accuracy and specificity.
2. The conventions of the classification and Official Guidelines for Coding and Reporting dictate how ICD-10-CM and ICD-10-PCS codes are assigned. Detailed knowledge and recall of the conventions of the classification systems and the guidelines that govern its application are key to CCS exam success as well as CDIS efficacy.
3. Coders and CDIS are on the same team but maintain different objectives in relation to documentation. Communication and a strong working relationship between the CDIS and coder are vital. CDIS that are also CCS can bridge the communication gap and provide important insight to both functions.
4. The success of inpatient CDI programs has encouraged some hospitals to expand the role of the CDI Specialist to outpatient services (surgical day care, emergency room, radiology, etc.) as well. Many CDIS, as second career clinicians, have little knowledge or experience of CPT coding. The level of CPT knowledge necessary for CCS exam success will position these CDIS with the CPT skills needed as the CDI function pushes further into outpatient services.
The revenue cycle function is critically important to the viability of our hospitals. CDIS with that extra knowledge of coding can provide significant value to their employer.
CDI Professionals: Get the training you need to prepare for the current AHIMA CCS Exam with Mary Beth York’s CCS for CDI: CCS Exam Prep for CDI Professionals. Learn more here.