CDI step by step
I am struggling to get help from my coding department. I have basically made up a job and found ways to help educate physicians since I have not been able to get any help from coding. I finally have managed to get a meeting with the HIM and coding directors and the CFO of my hospital and I was wondering if someone might have the time to give me a step by step on what an RN working as CDI does. I have taken the boot camp and I know that CDI helps to develop a working DRG and make sure there is documentation to support that DRG but I am not sure how you come up with the DRG if you are not a coder. Currently the coders query physicians for missing documentation but they do not allow me to do this.
I would very much appreciate it if an RN CDI out there could walk me through what you did to get started .
Theresa Crosslin RN CM
Cookeville Regional Medical Center
931-783-2078
TCrosslin@crmchealth.org
I would very much appreciate it if an RN CDI out there could walk me through what you did to get started .
Theresa Crosslin RN CM
Cookeville Regional Medical Center
931-783-2078
TCrosslin@crmchealth.org
Comments
Do you have the CDI handbook? I was in a similar position (no experience, one women show) when I started 5 years ago and I found that very helpful.
As far as the issues with coding, are you under HIM or which dept? I would start by explaining to them that the role of CDI is to make sure that information required for coding is in the record prior to discharge. This makes their job easier by reducing retro queries. Additionally CDI makes sure that the clinical picture is being presented in a way that can be accurately captured by coding. CDI is interested in ensuring that the patients true SOI/ROM is being captured. This means you look for clinical indicators of diagnoses that are NOT documented as well as clarification (specificity) of existing diagnosis. You then query for this information concurrently, while the patient is still in house. Be sure to make sure you bring the AHIMA/ACDIS query brief with you. This is something both coders and CDI should adhere to and specifically spells out when queries are indicated.
As for aggregating a DRG: you aggregate your DRG based on your Primary dx, CC/MCC’s and principle surgical procedure. You don’t need to code the record to do this. If you don’t have a DRG Expert, get one. This allows you to get to your DRG without coding the record. You also can use the encoder to aggregate the DRG (this is what coders do). Some established programs do not assign working DRG’s but I think it’s helpful, especially when you are learning. We do assign, partially because other departments (ie case management) use this information.
Who is telling you you ‘cant’ send queries. This is the foundation of CDI work.
For what it’s worth, you are not dependent on coding to do your job. Ideally CDI and coding work together to ensure the most accurate record but you can perform your role as far as clarifying documentation regardless of whether coding is engaged….
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
If you are being told you can’t issue a query, there really is no reason for your role to exist as that is ‘what we do’?
Agree w/ Katy’s advice…since you are participating in CDI talk, you have access to multitudes of excellent resources in the ACDIS web site. See the tools, links, library section, and so forth. There is a wealth of information at the website.
Best luck.
Paul
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
I want to start out by saying the RN(Clinically Documentation Specialist) is not a coder, having said that it is very important that you use the clinical experience looking at the patient chart in real time and make sure that the Hospitalist are documenting all the specificities needed to obtain the correct DRG. I use the DRG book a lot because it expands the possibilities of bringing up the Weight of the DRG. Coders only document what they see on the screen, but it is my job to get all the details of what is clinically going on with the patient. Example, when an hospitalist documents CHF then you should be asking yourself did the pt have a Echocardiogram noting the Ejection fraction and if the EF% is above 50% then you should be querying the hospitalist for the TYPE-diasolic/systolic Acuity-acute, chronic, or acute on chronic The coders are only going to code the CHF. The type/acuity that the CDS queried for brings the wt way up and if you are using Acute diastolic CHF as an MCC then it will increase the weight. The coders and CDS should be working as a team and when CDS DRG doesn’t match the coders that’s when communication between the two come into play. The coder might not have seen the clinically details needed to bring up the Weight. I have wonderful coders at our hospital we work as a team. Learn to use the DRG book, the Electronic Coding like 3M is nice but when you depend on the coder to do all the work than the CDS has trouble expanding their education and knowledge on what is really needed. Senior leadership really needs to behind this program and it will make a big impact Financially and appropriate care of the pt. Sorry like this seemed like a book, but we have been doing the CDS for 9 months and it has made a big impact financially, documentation from staff and hospital have improved patient care.
Best of luck!
Renee
Perhaps you don't realize it, but most, if not all, coders recognize the clinical indicators of a CHF exacerbation, and they would know to look at an echo to determine the Ejection Fraction. In addition, most, if not all, coders would know how, and have, composed intelligent queries seeking CHF specificity - along with a multitude of other disease processes. I personally do not know one coder who "just codes what they see." Coders are very well aware of the nuances of documentation requirements, and have been querying physicians for many years - long before CDI Programs became popular. They are required to understand anatomy, physiology, and pathophysiology for all, or at least a variety, of medical specialities. And most coders have earned higher degrees and hold multiple certifications.
Again, I'm sure you didn't mean to offend anyone, and I'm glad to hear you have a good working relationship with your coders, but the mindset that only RNs can identify clinical indicators is an erroneous and offensive misconception. Please remember, not all CDI Specialists have a nursing background. In my opinion, it is the multidisciplinary teams that are the strongest.
Thank you.
Donna Fisher, CCS, CCDS, CHC
________________________________________
HI Theresa,
I want to start out by saying the RN(Clinically Documentation Specialist) is not a coder, having said that it is very important that you use the clinical experience looking at the patient chart in real time and make sure that the Hospitalist are documenting all the specificities needed to obtain the correct DRG. I use the DRG book a lot because it expands the possibilities of bringing up the Weight of the DRG. Coders only document what they see on the screen, but it is my job to get all the details of what is clinically going on with the patient. Example, when an hospitalist documents CHF then you should be asking yourself did the pt have a Echocardiogram noting the Ejection fraction and if the EF% is above 50% then you should be querying the hospitalist for the TYPE-diasolic/systolic Acuity-acute, chronic, or acute on chronic The coders are only going to code the CHF. The type/acuity that the CDS queried for brings the wt way up and if you are using Acute diastolic CHF as an MCC then it will increase the weight. The coders and CDS should be working as a team and when CDS DRG doesn
Paul
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
Thanks, PE
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org