CDI Opportunities for Coding Professionals


by Richard D. Pinson, MD, FACP, CCS

As a result of the COVID-19 pandemic, many CDI nurses have been repurposed to clinical care and hospitals are relying on coding professionals to fill the CDI void. What must coders do to accomplish this task for their hospital?

Perhaps the most immediate need is acquiring more clinical information to recognize undocumented medical conditions for which there is strong clinical evidence (diagnostic criteria) that would prompt a CDI query.

This doesn’t require coding professions to study a ponderous medical textbook or recognize all the diagnoses in every MDC. Only about 50 specific medical conditions constitute 90-95% of the inpatient queries needed, such as systolic/diastolic heart failure, encephalopathy, respiratory failure, acute kidney injury, morbid obesity and the like.

In addition, the coding professionals’ query construction skills may need to be sharpened. To improve query composition and editing of templates, the hospital’s most experienced documentation specialist could offer examples and provide coaching for their coding colleagues.

While COVID-19 is the immediate precipitant of this opportunity, it may result in a permanent opening of this career path to non-clinical staff. Hospitals able to take advantage of their skilled coding staff and offer this opportunity for advancement will find a willing and able workforce at the ready.

 

Pinson & Tang CDI Pocket Guide
Libman Education offers many resources for coding and documentation specialists. Perhaps the most popular is the Pinson & Tang CDI Pocket Guide recognized by CDI professionals for over thirteen years as their “CDI Bible!”

The Pinson & Tang CDI Pocket Guide provides specific standardized query templates for the most common medical conditions as well as instruction on how to modify the template to fit the particular circumstances of the case in question.

A set of free standardized query templates is available for free on the Pinson and Tang website. Select “Resource” tab and search “Queries.”

About the Author

Dr. Richard Pinson, MD, FACP, CCS
Dr. Richard Pinson is a physician, educator, administrator, and healthcare consultant. He practiced Internal Medicine and Emergency Medicine in Tennessee for over 20 years having board certification in both. Dr. Pinson is a Fellow of the American College of Physicians and former Assistant Professor of Clinical Medicine at Vanderbilt, and has assisted hospitals as a physician consultant for the past ten years. Dr. Pinson’s personal understanding of the mindset of both doctors and managers allows him a unique vantage point from which to promote cooperation between physicians, hospital staff, and administrators toward achieving beneficial and practical changes.

About the Author

Libman Education
Libman Education Inc. is a leading provider of training for the health care workforce offering self-paced and instructor-led online courses designed and developed by leading industry experts in Health Information Management (HIM) and Medical Record Coding. Our courses are specifically designed to improve individual skills and increase the efficiencies and competencies of health care providers and institutions. At Libman Education, we understand the needs and challenges of a well-trained workforce and offer the right-mix of online education to ensure that the health care professionals are prepared to meet the challenges of the changing workplace.

5 thoughts on “CDI Opportunities for Coding Professionals

  1. Carolyn Sawrie, CCS - May 20, 2020 at 3:09 pm

    Coders are trained to be clinical and know more about queries than anyone gives us credit for knowing. Contrary to popular belief we are not idiots. I’ve been coding since 1985 and always worked closely with the medical staff when they couldn’t cut and paste their progress notes. They had to write one every day and be certain that all abnormal labs, etc. were addressed.

    • Tennille Kress - May 20, 2020 at 5:29 pm

      Yes!!! Thank you Carolyn.

      I don’t understand why it is “clinical” personnel either. Look at our education requirements.

  2. Lisa Wouters - May 20, 2020 at 5:15 pm

    clinical definition-relating to the observation and treatment of actual patients

    • Tennille Kress - May 21, 2020 at 3:42 pm

      I understand that. We are trained that way as well, that is how we do coding queries. We do utilization review, etc.

      We are trained to recognize clinical issues as well. If we do a coding query for a diagnosis not documented, like sepsis we have to know the clinical indicators and recognize the treatment for sepsis. That allows us to ask if a condition is present. Like a CDI role.

  3. Tennille Kress - May 21, 2020 at 3:44 pm

    I understand that. We are trained that way as well, that is how we do coding queries. We do utilization review, etc.

    We are trained to recognize clinical issues as well. If we do a coding query for a diagnosis not documented, like sepsis we have to know the clinical indicators and recognize the treatment for sepsis. That allows us to ask if a condition is present.

    Like a CDI role, if I am not mistaken.