Second Level Review

ccuneyccuney
in CDI Talk Archive
Has anyone created a "form" for their second level review? I am defining second level review as sending an account to a Lead Coder/Coding Manager when the coder and CDS cannot see eye to eye on the final DRG.

If so, please send me a copy.

Thanks,
Carla Cuney
CDI Manager - ICD-10 Program
Glaza Inc on contract with UT MD Anderson Cancer Center

Comments

  • vanessa.falkoffvanessa.falkoff
    edited May 2016
    Here is the one I have for Physician review - you may be able to tweak it :)

    Vanessa Falkoff RN
    Clinical Documentation Coordinator
    University Medical Center
    Las Vegas, NV
    vanessa.falkoff@umcsn.com
    office 702-383-7322
    cell 702-204-0054



  • paxnerospaxneros
    edited May 2016
    We don't have a 'form" just notify the Lead Coder and CC the Coder by email w/supporting info.

    If Lead can't make a decision she forwards to coding supervisor. If coding supervisor cannot make the decision we refer to outside auditor. The outside auditor has final say.

    N Brunson, RHIA,CDIP,CCS,CCDS


  • ccuneyccuney
    This is great for query review but I was looking for a review form when the coder and CDS do not agree on the Final DRG and the reason for choosing the Final DRG.
  • judithbatesjudithbates
    edited May 2016
    This is the one I developed and have used for a couple years...Works well for us...

    Judi Bates RN, BSN, CCDS
    Our Lady of Lourdes Medical Center
    CDI Specialist
    856-757-3161
    Beeper 66x2906
  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    Reviewing sample procedure in Forms & Tools library might have content useful (though no form):
    "CDI program practice policy"
    http://www.hcpro.com/content/280691.doc

    There is a short process outlined there. First level is a designee of the Coding Manager (for us, either an auditor or coding supervisor), secondly a collaboration by the Coding and CDI manager. Option remains for the 2 managers to send to external consultant for input.
    For my perspective, the Coding manager ALWAYS has the final say on coding practice and I will back her up 100% -- though we may have a healthy and respectful private conversation first :) , the coding manager decides issues of coding practice. Equally, she listens closely to me on clinical matters.

    Don

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