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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 fifth installment of this discussion, three of the experts are asked about the cases they or their staff struggle with most, and why; as well as what’s typically missing from the documentation. (See the series in its entirety here.)
ERAMO: What are the cases you or your staff struggle with most, and why? What’s typically missing from the documentation?
TROMBLEY: Sometimes it’s not about what’s lacking—it’s about what’s already there. Some physicians copy and paste diagnoses without updating the assessment and plan. CDI specialists can get lost in conflicting documentation. CDI teams, IT, and physicians all need to work together to solve this problem.
LA CHARITE: Acute encephalopathy cases can be challenging because providers are sometimes too lenient with this term. They document it when there’s only a slight change in a patient’s mental status. In terms of documentation omissions, we sometimes see cases where the patient met criteria for sepsis or renal failure, but the physician didn’t document it.
LAFRAMBOISE: There’s never a day when sepsis isn’t a big concern. There are state programs that penalize hospitals for not recognizing sepsis as early as possible and treating it as aggressively as possible. When we do second-level reviews for UTIs and simple pneumonias, sepsis is often found as well. It’s missed on the first-level review by the CDI specialist. The interesting thing is that if you read the records, physicians treat the sepsis correctly (meeting the three- and six-hour bundle), but they forget to write the word sepsis. Other cases where documentation is lacking include acute blood loss anemia, encephalopathy, complex pneumonia, and malnutrition. Thirty-five percent of patients in the acute clinical setting have some degree of malnutrition, and hospitals don’t pick it up nearly as frequently. Malnutrition is such an important driver of mortality, so we don’t want to miss that. Another area of concern is complication coding. When is it truly a complication of a surgery versus an expected post-operative event? The language can be so nuanced.
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
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
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