CDI and the Encoder

I am interested in thoughts about CDI and use of the encoder. Our CDI’s have always had access to the encoder. I personally have tried to avoid being overly reliant on it. When doing concurrent reviews I try to work primarily out of my DRG expert and probably use the encoder on 10% or so of my cases when I am not sure about something. However, we now have several new staff members and that all seem to love inputting everything in the encoder. I have encouraged them NOT to do this for several reasons including:
1. They are not coders, we are not tasked with ‘concurrent coding’.
2. Time consuming
3. Does not lead the CDI to question what dx may be missing, only focuses on specificity.
4. CCDS exam is with the book only.

However, in some ongoing discussions about I-10, a suggestion was made that we use the 3M training module and ‘duel code’ the records to look for the missing concepts. I’m a little resistant to this idea since I have been trying to get my team not to rely so heavily on the encoder. But maybe I am thinking about this the wrong way. What do you think??


Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

Comments

  • Ying/Yang to both sides of the argument.

    1. It is not always feasible to accurately compute the MS-DRG for 'complicated' case manually.
    2. The Encoder will suggest clinical outcomes for the CDI - yes, these must be confirmed, but the permutations are computed by the laptop.
    3. The Encoder will offer valuable resources, such as Coding Clinic, that must be considered by CDI staff
    4. The Encoder will accurate report the realized revenue for all cases if the financial tables are current
    5. It is surely not feasible to compute the SOI/ROM w/o the APR-DRG Encoder - all Encoders should compute the MS-DRG and the APR-DRG

    5. One negative aspect, overuse of the Encoder does in fact lead to 'Encoder Dependency' - I have known coders that rely too heavily on the Encoder for coding advice.



    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org
  • RE: Dual Coding....that would be quite a challenge in terms of productivity. I'd suggest some practice with ICD-10 prior to roll out and save the Dual Coding and GEM for the coding teams.

    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org
  • Absolutely Paul!

    I am trying to figure out where my happy medium is.

    There are situations where I definitely think a Encoder should be used. I encourage the CDI's to use it in complex cases where they are unsure of a DRG. Or in cases where death is expected to evaluate the SOI/ROM (I ask them to send it to me for a second level review if the SOI/ROM is low).
    Coding clinic is invaluable and I use the encoder for this though we also have it available in our CDI software.
    I just don’t want the, getting too caught up on the 'coding' part of this job and missing the potential dx that are not documented (ex, pt is on lasix but has no corresponding dx).

    I appreciate your feedback!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • I agree with your approach. I do not use the Encoder for every case, either. Rather, I use it for difficult cases, research and reconciliation.


    But, it can be very educational to ask someone 'new' to CDI to use an Encoder - there is much information embedded with an Encoder that can be very helpful to anyone performing CDI. However, I certainly agree there is no need for CDI to code to final coding product status.



    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org
  • Yes, this was brought up when we were discussing when the coders would begin duel coding. CDI has been tasked with I-10 MD education and we are heavily involved. We are attempting to assess risk as well but of course I feel like the real test will be duel coding. I was saying I am really looking forward to the coding feedback and the response (from coding) was 'why don’t you duel-code now then'? This was not suggested rudely or anything, I just am somewhat resistant to agreeing to that approach.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • Absolutely! You can learn so much about underlying causes, sequencing, etc that is sooo helpful to being an effective CDI. But on a chart-by-chart basis, it's too much. Especially if you take into account the re-reviews. It just doesn’t make sense to 're-code' a record repeatedly.

    Thanks so much for your help Paul, as always. Have a great weekend!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • I agree with your approach....dual-coding better suited for coding rather than CDI for a number of obvious reasons.

    (No way I'm gonna do it) :)




    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org
  • ;-)

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • edited May 2016
    I use the encoder only with difficult cases that I need help with. It is time consuming.

    Tracy M Peyton RN, CCDS
    Bradford Regional Medical Center
    Upper Allegany Health Systems
    116 Interstate Parkway
    Bradford, PA 16701
    814-558-0406
  • Hi, Norma

    Yes, I remember using the 3 volumes of books ‘back in the days at the university’. I STILL have hard copies of books that I use as a reference for really technical and difficult cases. I 100% agree with you that using the Encoder has a place for CDI. For many cases, I actually do not need either the Encoder or the DRG Expert since I know what to review – but, as you stated, sometimes use of the Encoder is a must.

    When ICD-10 is rolled out, there will be a huge learning curve and I plan to use both manual code books as well as an Encoder – I am certain my personal productivity will significantly decline with ICD-10; nothing can be done about that, it is natural and expected because we will all be learning a new language.

    Paul

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org
  • Yes, I do see the encoder as a helpful tool and I can also see its utility being very different depending on your background as well as the focus of your program/where it is housed.

    For me, the purpose of the encoder is to evaluate complex scenarios, find codes that I may need for a variety of reasons, evaluate SOI/ROM. However, this is not required for every patient, in my opinion. I agree that the encoder is faster than using a Coding book but for a concurrent review I rarely think that codes need to be assigned. I am focusing more on concepts. My thinking tends to go along this route:

    1. What was the reason for admission? (Pdx)

    2. What were the main contributing dx?

    a. Are we using language that will be useable by coding?

    b. Could these dx be further specified to improve SOI/ROM or create a clearer clinical picture (underlying cause, etc)

    3. What are we treating/monitoring that is not explained in the documented dx?

    4. What is the resultant DRG?

    For most of the ’run of the mill’ cases, an encoder is unnecessary for all of that. For an experienced CDI, a DRG book is likely also unnecessary for the majority of these cases either because if you do not rely on the encoder you will quickly memorize most of your common DRGs. Even when we are thinking about SOI/ROM, we don’t necessarily need to code these out. We can’t make dx out of thin air so the question really is ‘do the dx listed explain the severity of the patients illness or is something going undocumented/unspecified’?. If we find out we have a patient that is expected to die on this admission and we calculate their risk at a 3/2, this is only so helpful. If we have accounted for all relevant co-morbidities, there is nothing we can do. We can likely have just as much impact by simply ensuring that our documentation is complete and specific for the relevant diagnoses. At my facility we DO assign a working DRG and I do want my staff to get progressively more accurate about this. But when it comes down to it, how much does it matter that there are sequencing guidelines related to ‘lysis of adhesions’ (for example)? If they do not know this initially (I do think they should learn these things over time) they will not be accurate on that DRG but the important thing is that the diagnoses were all accurately and effectively documented. The DRG assignment is somewhat of a formality. I realize that this may vary program by program and I don’t think there is one way to set up an effective program. This also doesn’t mean that I don’t think the encoder is valuable. It is! And you certainly learn by using it. I just don’t think we should feel the need to use it on most cases, especially if you are a ‘seasoned’ CDI.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • edited May 2016
    Well put KATY! Excellent Summary!

    Vicki S. Davis, RN CDS
    Clinical Documentation Improvement Manager
    Health Information Management Department
    Cone Health at Alamance Regional
    Office (336) 586-3765
    Ascom Mobile (336) 586-4191
    Fax (336) 538-7428
    vdavis2@armc.com
  • Katy -- you do present a challenge that I might not be able to resist
    ... searching back through the archives of CDI Talk now!
    (better look for my early posts first though -- got to be some real
    doozies)

    ;)

    Don
  • Hahahaha! You won't have to go back too far for me Don!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • edited May 2016
    Encoder dependency and/or ICD-10 training:

    I think the encoder is a great tool. That being said, many CDS were never taught to consider or acknowledge the many built-in notes/edit comments saying why a selected or entered diagnosis is inappropriate. I think CDS all need a "coding 101" to explain the meaning of concepts such as "code first", "code additional", "manifestation codes", etc., so that they will understand the proper use of an encoder.

    That being said, even now, CDS do not often consider that the multiple screens that appear (I'm thinking of 3M, for example)as you enter a diagnosis, are in essence, providing query opportunities for diagnostic specificity. A good example is pneumonia, or stroke. Each screen is asking "does it say this, or that" until you get to the end.

    If CDS start paying attention to these questions (screens) this can be a good way to learn what level of specificity/information is required for accurate ICD-9 (and for sure, ICD-10) coding.

    We all have to get off the DRG couch and start thinking "diagnostic specificity". Why? The codes we report beginning 10/1/14 will be uses to re-calculate relative weights and CC/MCC designations in the future.

    We all know that when it comes to CDI, no good deed goes unpunished, especially when it comes to CMS. All of us need to start thinking diagnostic specificity NOW, so that ICD-10 documentation clarification won't be an overwhelming burden.

    Using the grouper effectively now and really taking a look at how much specificity in information is "requested" by the grouper, will go a long way in helping us understand what may be documentation opportunities that we've been overlooking in favor of that CC or MCC.

    Trust me on this -- by 2015 or 2016 we will see sweeping changes in the CC and MCC lists based on the volume of "unspecified" or codes without the highest level of detail reported in 2014.
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