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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.
ERAMO: 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.
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.
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. 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.
LA CHARITE: 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.
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.
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.
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.
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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