Needing advice
I and my other CDI associate are under the supervision of the Coding supervisor now for the last three months. We work in a 200 bed hospital that does everything but neurosurgery. Now she is asking us to fill out a CDI worksheet manually with the Principle diagnosis , CC's MCC's Initial DRG with the Weight, SOI/ROM. Then with queries-Potential DRG, Weight, SOI/ROM and the final Weight, DRG SOI/ROM. Our census is in the 120's-170's. She expects us to do the entire hospital -initial review and our CDI work and now these sheets on top of it. I told her I did not think I could do this alone when my coworker is on vacation. Am I slow or is she correct? She said they use to do all this with one coder. I do not see how one person could do all of this. Please be honest. I need an answer because I am very overwhelmed at this point.
Mary L. Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
740-689-4443
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Comments
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From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Monday, June 29, 2015 08:36 AM
To: Hutchinson, Claudine
Subject: [cdi_talk] Needing advice
I and my other CDI associate are under the supervision of the Coding supervisor now for the last three months. We work in a 200 bed hospital that does everything but neurosurgery. Now she is asking us to fill out a CDI worksheet manually with the Principle diagnosis , CC's MCC's Initial DRG with the Weight, SOI/ROM. Then with queries-Potential DRG, Weight, SOI/ROM and the final Weight, DRG SOI/ROM. Our census is in the 120's-170's. She expects us to do the entire hospital -initial review and our CDI work and now these sheets on top of it. I told her I did not think I could do this alone when my coworker is on vacation. Am I slow or is she correct? She said they use to do all this with one coder. I do not see how one person could do all of this. Please be honest. I need an answer because I am very overwhelmed at this point.
Mary L. Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
740-689-4443
---
CHRISTUS Santa Rosa New Braunfels
CDI Specialist
cynthia.hudson@christushealth.org
830-643-6116 (Office)
830-643-5139 (Fax)
[CCDS_pin_1inch]
"We are His hands". Isaiah 64:8
Syndi Hudson, RN, CCDS,CCM
CHRISTUS Santa Rosa New Braunfels
CDI Specialist
cynthia.hudson@christushealth.org
830-643-6116 (Office)
830-643-5139 (Fax)
[CCDS_pin_1inch]
"We are His hands". Isaiah 64:8
Marty
I for one, think that first and fore-most we need to get back to the basics of "reviewing our patients". I do agree we need, and should be involved in extra duties where necessary, but it seems our scope has gotten out of control.
For you, I would question HOW just the two of you should be expected to do this? What is the purpose of this? Are you a hybrid system, or all computerized? I would think if you are computerized that HIM could create reports that give her all that data! Isn't that data that you can get from the coding data/abstract database once the charts are coded? If you are not computerized, and are hybrid or still on paper, I would suggest then that they hire a consultant group for your CDI that could extract that data and enhance your program to show your impact. I think it is unrealistic to expect this of a 2 person team. How do you do your daily workflow currently? On paper etc? Where is this information going that she wants to extract?
I don't think even with the two of you and your census, that you can do a thorough review if you are BOTH there, let alone when one is on vacation! My institution has SIX CDI for a total bed of 400, AND we only review Medicare patients!
Good luck! I know it is overwhelming.
Juli
Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
755-8426 (work)
786-2677 (cell)
"No Limit to Better......"
[CCDS_pin_1inch]
My research led me to these numbers:
CDI RN = 1 per 1600 discharges per year with CDI software /1 per 1400 discharges per year without CDI software. This does not include meetings outside the dept., Physician education, or additional specialized review for HACs, PSIs or Mortality.
We average about 20 reviews each per day, including discharge reviews, follow ups, and initial intakes.
I liked the suggestion to do what she instructed and document the amount of time spent and its effect on your productivity.
Also, there is information available on the ACDIS website about staffing.
Good Luck,
Vanessa Falkoff RN
Clinical Documentation Improvement Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
I am also coding some cases in 1-10, and the PCS portion is very technical.
I'd cite the ACDIS website information about staffing given this is an Industry Standard.
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: 415.412.9421
evanspx@sutterhealth.org
Mary L. Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
740-689-4443
Perhaps this could inspire the need for an additional co-worker to be hired which would provide for a better experience when vacations are taken?
Also; while the tracking forms may slow things down a bit, they can also provide some important data for management and senior management as well as other parties that are positivley impacted by all of your hard work.
And! what would a hospital be if not for more paperwork
If you are using a CDIS program on your computer this should have an option to print these forms/reports out without many extra steps.
Axel Olson RN,CCDS
Axel.olson@essentiahealth.org
...she said they did this all with one coder....
I question if she understands how the difference between the role of a CDIS and a coder impacts time spent per chart as well as physician education?
Coders seem to go throught charts a bit faster than the CDIS because the CDIS role is to "scrub the chart" and not just code as is.
of course coders have to read in context as well... but they are not searching in the same manner as a CDIS.
the difference in roles ought to highlight the percieved productivity discrepency between the two.
I have seen the below used.. not sure if this is industry standard or not. ACDIS likely has something up to date to say about productivity guidelines.
Axel Olson RN, CCDS
Estimated # of CDI Chart Reviews Per Day
100% Paper Record Total # Charts Reviews/Day (new and subsequent reviews)
Experience Level of Reviewer
Up to 1 Month *3-5
2-6 Months *6-10
7-9 Months *15-20
10-12 Months *20-25
> 1 Year *25-35
Hybrid Record (1/2 paper, 1/2 electronic)
Experience Level of Reviewer
Up to 1 Month *3-5
2-6 Months *6-10
7-9 Months *11-18
10-12 Months *19-23
> 1 Year *25-30
100% Electronic Record
Experience Level of Reviewer
Up to 1 Month *2-5
2-6 Months *6-8
7-9 Months *9-13
10-12 Months *14-18
> 1 Year *19-28
Note: Estimates based on medical record reviews for diagnosis/procedure clarification only
For each additional review responsibility*, subtract 5% from estimates
* CORE Measures
* Present on Admission
* Medical Necessity
* Severity of Illness/Risk of Mortality
Mary L Snook RN-BC
Clinical Documentation Improvement Specialist
Fairfield Medical Center
Lancaster, Ohio 43130 740-689-4443 snook@fmchealth.org
With ICD 10 coming our CDI group has been responsible for rewriting queries, educating providers, attending more meetings, as well as doing our normal second level death reviews, orienting Residents and new providers, attending Hospitalist meetings, attending Specialty provider meetings-and on and on. Some days I think we just need to be able to review patients-though I know that a CDI has many roles!
I always have to tell myself at the end of the day "I can only do what I can do". For you, in your case, if your institution will only give you an inch, then you can only work with an inch! My old CEO used to say; "a review rate of 60% was better than a review rate of 59%"! We now have a new CMO who asks "how can we get to 100% (we are currently > 90% for Medicare pts). You can only do what you can do! Keep your chin up and just know you are doing your best!
Juli
Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
755-8426 (work)
786-2677 (cell)
"No Limit to Better......"
Juli
Mary
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, July 08, 2015 8:26 AM
To: Mary Snook
Subject: RE: RE:[cdi_talk] Needing advice
I DO feel that for a CDI position, there is a DIFFERENCE between RN and coder in this role! I know our coders look at things very differently when they are coding a chart than what a CDI looks at. They have different education, and thus entirely different ideas about diagnosis, treatment etc. Almost every day we have discussions with our coders related to a diagnosis and coding relative to treatment provided or rendered, clinical issues and indicators-almost always they agree they didn’t look at it "that way" or didn’t know clinically what they were seeing! Not knocking coders-they just have a different role. We appreciate our coding staff and I would never want their job myself! They do a magnificent job! But, for myself, I would rather have an RN in the role of a CDI in the department rather than a coder. There is a difference. NOT better or worse, just different!
Juli
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, July 08, 2015 6:18 AM
To: Bovard, Juli
Subject: RE: RE:[cdi_talk] Needing advice
RN vs Coder - again. Why not hope for the best candidate - regardless of professional background?
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, July 08, 2015 8:10 AM
To: Fisher, Donna L.
Subject: RE: RE:[cdi_talk] Needing advice
I wish to thank everyone who gave me advice and formulas to help me present at my meeting. I had the data for 3 CDI and at present have 1.5 CDI. I will get another half of a position. The Coding supervisor holds the key to whether it is a coder or an RN. I hope it is an RN as most of our coders have < 5 years experience coding and only one has > 6 months doing IP records. I cannot do it all but what will be will be. I am discouraged but not hopeless. My coworker who is an RN is retiring in January.
Mary L Snook RN-BC
Clinical Documentation Improvement Specialist Fairfield Medical Center Lancaster, Ohio 43130 740-689-4443 snook@fmchealth.org
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, July 07, 2015 4:15 PM
To: Mary Snook
Subject: RE:[cdi_talk] Needing advice
P.S.
...she said they did this all with one coder....
I question if she understands how the difference between the role of a CDIS and a coder impacts time spent per chart as well as physician education?
Coders seem to go throught charts a bit faster than the CDIS because the CDIS role is to "scrub the chart" and not just code as is.
of course coders have to read in context as well... but they are not searching in the same manner as a CDIS.
the difference in roles ought to highlight the percieved productivity discrepency between the two.
I have seen the below used.. not sure if this is industry standard or not. ACDIS likely has something up to date to say about productivity guidelines.
Axel Olson RN, CCDS
Estimated # of CDI Chart Reviews Per Day
100% Paper Record Total # Charts Reviews/Day (new and subsequent reviews)
Experience Level of Reviewer
Up to 1 Month *3-5
2-6 Months *6-10
7-9 Months *15-20
10-12 Months *20-25
> 1 Year *25-35
Hybrid Record (1/2 paper, 1/2 electronic)
Experience Level of Reviewer
Up to 1 Month *3-5
2-6 Months *6-10
7-9 Months *11-18
10-12 Months *19-23
> 1 Year *25-30
100% Electronic Record
Experience Level of Reviewer
Up to 1 Month *2-5
2-6 Months *6-8
7-9 Months *9-13
10-12 Months *14-18
> 1 Year *19-28
Note: Estimates based on medical record reviews for diagnosis/procedure clarification only
For each additional review responsibility*, subtract 5% from estimates
* CORE Measures
* Present on Admission
* Medical Necessity
* Severity of Illness/Risk of Mortality
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Fairfield Medical Center
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I am tired of this conversation, and so must everyone else be?
In my system, we have five major CDI cells, 2 are lead by RNs, 2 are lead by RHITs, and I, an RHIA, lead the other. The coding professionals lack nothing in regards to clinical awareness and knowledge that would preclude us from leading CDI teams....the coding leaders participate fully in any/all clinical conversations, to include recognition and use of evidence and consensus definitions for both coding and CDI purposes. I must be working in some type of Jerry Springfield alternative world as the RN and RHIT/RHIA members work together seamlessly in my system????
I have met, and worked with brilliant RNs, filled w/ clinical knowledge. I have also worked with more than few on the other side of spectrum. I can also say the same about coders...Bell Shaped Curve w/ points along the total spectrum.
I have worked with some RNs, and been entirely unimpressed w/ their clinical knowledge...simple fact. If they worked as clinicians, then somehow they lacked the training and education that would allow them to review a chart and recognize ATN, Sepsis, Aspiration Pneumonia, Drug-Induced Pancytopenia, Acute Respiratory Failure, Type II MI in the setting of Sepsis......(the list goes on).
Again, not the norm. But, same pertains to coders.
Further, advanced coding practice IS a positive factor in regards to any and all CDI work..somehow, these conversation about RNs versus "coders" always seem to focus on what so many of you (falsely) think ALL coders lack rather than focusing on the complexity of coding charts, which is a tremendous asset in the CDI practice...how many of you are going to be able to Reconcile to the precise DRG when we begin to use I-10? Have you thought about it?
Also, have any of you noted that the 'coders' on this blog do contribute disproportionately to the conversations and blogs pertaining to both clinical and coding issues??
We should recognize that the old days when a coder only 'coded what the MD stated' are over and have been over for some time. CMS, working via the RACs, is now formally stating that even 'when a condition is stated, it should be verified by a CODER if/when clinical criteria is not met'. So, how can any institution tolerate using coders lacking formal clinical knowledge? Is this a local practice...are there certain States that it is so difficult to find a 'coder' that any warm body is employed? Do your 'coders' take classes for 2 days at some weekend community college course, and then market themselves as coders?
I will repeat what I have said too many times....it seems too many people are functioning in some hospitals as coders, but apparently w/o much, or any, formal education. Unfortunately, this is permitted by the industry. Please be careful with your paint brushes as some of you are painting very far outside of the lines w/ huge strokes.
I do NOT have a different idea about how to recognize, query for, or code for any diagnosis relative to any other person that holds the CCDS credential.
I 'vet' every major clinical condition as I work as a CDI professional or as a coder, and have done so for decades. I was trained, at the University, to work in this fashion. As I work as a coder/CDI, I know that some 3rd party very well may question my decision to code a certain condition, even if noted multiple times by an MD. I work w/ full knowledge of the impact of my coding decision upon a multitude of quality metrics.
I am held accountable by my institution to apply clinical review judgement as I work...hence, I can't fathom working in any other fashion.
I have worked extensively as a coder and as a CDI professional...in all honesty, the coding role is more difficult.
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: 415.412.9421
evanspx@sutterhealth.org
Renee
Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
Director, Clinical Documentation
Tanner Health System
I decided to email back because you say a lot in your email and seemed frustrated with “my” response (and/or others) in regards to Coders “VS” RN being in the role of a CDIS.
I, like you cannot imagine working with coders who lack clinical knowledge-or and RN/CDI that lacks clinical knowledge, but as it was stated by the initial thread/email in the CDI blog-it happens every day to many CDI staff. I respect our coders for their knowledge and expertise in their field-of which I deal with every day. I tell our coders all the time how I would not like to be a coder, how smart they are and how much we appreciate them. We currently are, and have been short coding staff at our facility, and I feel (as I have also been told by our coders), that they do not have the time nor expertise clinically to look at the whole picture-or scour the chart like the CDI do-and are unfortunately/fortunately have to rely on the CDI and our worksheets to assist with the DRG/PDX/CC/MCC for things they miss or discrepancies they may see. MOST days our 6 member CDI staff will have multiple calls and emails from the coders asking how, or why we got the DRG/PDX we did, and or/if a diagnosis should be coded relative to treatment, monitoring and if it should be on the DC summary. MANY times we cite coding clinics to the coding staff-just as they do to educate us! We BOTH have our roles-and I feel they are both different-again, not better or worse-just DIFFERENT, and yes it makes for a more cohesive TEAM approach that we both have our roles and look at things differently!
Yes, I think a coder could be trained to look at the charts more “clinically” like a CDI does, and yes, they have had to take A&P classes, but the crux of knowledge also comes from the years of education at the University level AND the 5 years clinical experience preferred at our institution as a CDI. Not to say our-or any coder doesn’t have that knowledge as well (as you stated), and not to say that all RN’s have the clinical knowledge needed to be a CDI, but coding education and CDI/RN education are different.
So, my email wasn’t meant to elicit a negative connotation of “vs” being better or worse-just DIFFERENT. I think for quality it is good for the institution that we both have different roles and can investigate the chart differently. And for myself, I didn’t know this was an issue with “coder vs CDI”! Again, not in any way putting a coder down or demeaning them in any way. We couldn’t and wouldn’t be able to do what we do and stay open as an insisitution without them. I don’t know what they get paid but, it isn’t enough.
Juli
I have seen at my own facility, the assumption being made by leadership that a nurse is by default able to perform as a CDI and that they are automatically the best candidates. And I can say from my experience that this is simply just not true...
I truly believe that a blended model is likely the most beneficial model. However, I think it ultimately each decision should come down to individual candidates and not educational background.
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
Ann
Mary Snook RN-BC CDI
Yes, I understand this chain goes long back, and my comments are not directed to you, or anyone personally. However, the theme recurs repeatedly.
There are a number of excellent friends and colleagues I have made via this organization, most of them RNs as ACDIS is populated mostly by RNs. I have great respect for many of you. (Thank you, Linda and Katy, for your support).
I will only comment, Juli, that if you are quoting Coding Clinic to your coding staff, that is a huge problem indicating a significant lack of professional knowledge w/ your coding staff. (Why)?
If you coding staff 'does not have the time' or 'expertise' to review each case, that is a huge problem for your institution, indicating management is not respecting the coders, nor allowing them time to work as professionals.
This will be my last contribution to the ACDIS Blogs until some future date; I'd encourage my coding colleagues that do contribute to this blog to continue to fight for the respect they deserve...consider my decision to cease my comments and contributions as my form of protest on this issue. I'd hope other 'coders' among ACDIS consider following my action. Perhaps this will garner some appreciation amongst the larger audience.
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: 415.412.9421
evanspx@sutterhealth.org
No angst from you for sure! As always there are about 10 sides to every pancake. I love that we can have a point to discuss, debate, think, enlighten and teach one another. I often get new thoughts and ideas from this site. I never take anything personally, and the "vs" issue for me was not an issue at all. I appreciate this forum and everything it provides and know it is only for the betterment of us all-CODERS, RN, CDI!
jULI
CDI is its own distinct profession--not a step on a nursing career ladder, and not an outgrowth of HIM. While it is a hospital-specific decision, ultimately it is the person and the personality, not the credential, that makes for a good CDI specialist.
We created the CCDS credential in order to acknowledge the distinct role and skillset of a CDI professional, and while it's not a perfect exam it's the best we could make it and we stand behind it.
Thanks,
Brian
Elaine Sakala RN
Clinical Documentation Specialist/UR
Delta County Memorial Hospital
esakala@deltahospital.org
970-874-2287
I can only state I would 'hope' that all in the profession would acknowledge that obtainment of the CCDS credential, in truth and practice, does " signify and acknowledge the distinct role and skill set of a CDI professional". O/W, a I am simply regarded as 'only' an RHIA, CCS, CCS-P, and in the views of some, not competent to work in CDI practice.
I dare say many reading this post have no idea what the credential "RHIA" signifies.
Thank you for allowing me to express my view.
PE
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: 415.412.9421
evanspx@sutterhealth.org