"sensitivity"

donna.kentdonna.kent
in CDI Talk Archive
I just had a physician ask me to be more sensitive to the clinical language that physicians use every day compared to the ICD 9 language that coders use. So, what is my job? I thought I played a bridging role between clinicians and coders so the chart would be as accurate and complete as possible when it goes for final coding.

Comments

  • robert.hodges2robert.hodges2
    edited May 2016
    Sounds like a challenge I had here at first. I had to explain to provider that for coders to code information accurately the documentation had to be a certain way. If they documented the way they were they may not accurately capture the severity of the patient's condition. Battle two is still linking signs and symptoms to underlying diagnoses. Most of them are starting to get it but it's ongoing.

    You definitely have an educational opportunity on your hands. Just wait until ICD-10 arrives.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
     
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    “Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge
  • donna.kentdonna.kent
    Yes I agree. We've been battling this for close to four years now. Here's the kicker. The doctor that said this to me is the Medical Director of the hospitalists AND used to work as a CDI consultant for Price Waterhouse Coopers. How's that for a battle?

    Donna
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