Standard CDI Practice/workflow

snchan1819

I've tried to look up if there are any best practice on CDI workflow issued by ACDIS but without success.  I believe in order to improve medical documentation and capture the appropriate SOI/ROM, you need (to at least try) to establish your inital working DRG by figuring out your PDx, procedure code(s), and if any, CC/MCC, whenever you're reviewing a chart. Afterall, if you don't know your baseline, how do you know what to query for that may affect your DRG?  And if you don't look up the codes in question, you may have queried for something that may not be coded (e.g. Excludes1) or that's in the CC exclusion list.  I believe this is especially important for new CDIs who are not familiar with all the different DRGs, CC/MCC, sequencing guidleines, etc.  However, some CDIs believe that looking up these codes and DRGs will not be the best use of their time.  I would like to know what others are doing.  Thanks!

cindys@hollandhospital.org

We do not look up codes or formulate working DRGs.   If we have a question about a diagnosis, we use a standalone Encoder and run the scenario through to see the impact.  This is on an infrequent basis for seasoned CDI but for our new CDI we encourage using the Encode often

katysuegood@gmail.com

our CDI's have access to the encoder and can look up/input codes if they desire. However, this is not the focus. Our facility has opted to query consistently for significant conditions (CC's, MCC's, quality dx, and discrepancies) regardless of impact so they do not need to know whether a dx would impact the DRG/SOI/ROM. The reason for this is that we are attempting to change documentation habits. If this is the goal, queries must be consistent for physicians to recognize their repeated deficiencies. Additionally, DRG optimization is not the focus of our program. We want consistent documentation across the board and even from a strictly financial standpoint, a single MCC is not a reason not to query for additional ones.

I do use the encoder at times, generally for complex cases. But as a new CDI I almost exclusively used the DRGexpert. I have since trained our team over the last year and personally find that many CDI's are overly reliant on the encoder. I think it slows them down and does not encourage critical thinking. Don't get me wrong, its a very valuable tool. But I would rather they actually learn the coding guidelines by utilizing the book and reading coding clinics rather than  simply using the encoder.

Our CDI's do establish a working DRG.

Katy

jackietouch@aol.com

We are a fairly new (<2 year old) program and do enter codes for PDx, secondary diagnoses, and procedures that will impact DRG assignment. We also enter a working DRG. We will sometimes use the encoder to more easily see shifts in SOI/ROM (software is a little more labor intensive than the encoder) and will sometimes use it for wording for clarifications so that we offer the provider an option that we know the coder will be able to see in the encoder (ie depth of tissue for debridement, etc).

Jackie Touch
CHOC Children's, Orange, CA