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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 the Revenue Cycle function 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.
In the second installment of this discussion, several of the experts discuss the most important coding concepts for CDI specialists to master. (See the series in its entirety here.)
ERAMO: 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.”
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
LACHARITE: 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.
Lisa A. Eramo, MA, moderator and freelance writer
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
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
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