CDI and Coder
i have a few questions for all the CDIS here
1. do you think that if it worth spend time for some retrospective review? i thought our job is to do concurrent review.
2. if you found some missed query while you review chart retrospectively, what would you do? i have a CDI here try to change the coder's final code,and then put query in the discharge record,is it right thing to do?
3. what would you do if you disagree with coder's final code? one CDI here always confront the coder and cause conflictions, is it ethical?
thanks
1. do you think that if it worth spend time for some retrospective review? i thought our job is to do concurrent review.
2. if you found some missed query while you review chart retrospectively, what would you do? i have a CDI here try to change the coder's final code,and then put query in the discharge record,is it right thing to do?
3. what would you do if you disagree with coder's final code? one CDI here always confront the coder and cause conflictions, is it ethical?
thanks
Comments
2. Coders are able to query while they do their coding. If they chose not to and a query is missed, they still have the responsibility for the final coding of the chart. It may be worthy of discussion for education purposes, but I wouldn't request them to change anything.
3. My personal opinion is that since the coder has the responsibility, legally, for the final coding of the chart, I would not question their judgment. They have their own auditors come in to evaluate their work. Confronting a coder because the DRG's don't match in my mind isn't ethical, but it certainly doesn't help anything. For me it has always been a discussion to see how they came up with the DRG and sometimes it's something as simple as additional information the provider put in the discharge summary that wasn't in their daily notes. I view things like this as learning experiences. I am certainly not a coder and will never pretend to be one, but open communication has helped me be better at my job and I've even taught the coders a couple of things. I think coders and CDI's need to work as a team for the benefit of the patient and the completeness and accuracy of the medical record.
Just my opinion.
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
2. If the coder finds a query I should have caught, I often volunteer to do it for them.
3. If our DRGs do no match we discuss why. Most of the time the documentation has been enhanced since my last review. Rarely the coder has missed something.
The coders and the documentation specialist are on the same team.
Charlene
2. A patient record should be coded to reflect the true patient status for the patient's episode of care. CDI here will query concurrent and the retro queries are up to the coders. There have been very rare occasions where the CDI have done retro. queries and the retro queries that CDI typically have done have been at the request of the coding professionals.
3. As in [1.] we are not to confront the individual coders. We have to send all final code questions to the coding auditor.
Debbis S, UTSW
CDIs should be working together with coding. Hopefully, there is some process for collaboration. Certainly if a CDI looks at the final code and disagrees or doesn't understand how the coder arrived at the final code there is opportunity for discussion. Coders and especially certified coders are extremely proficient in their specialty. There are coding rules and regulations and nuances that most CDIs have not mastered. I am told a coder needs 3 years of experience before they take the certification exam. I believe the coder has the final word.
2. If the CDI finds a missed query, in many facilities they would have the coder follow it up. A coder may not feel there is enough documentation in the record to pursue it or the discharge summary may have negated it etc.
3. The CDI and coder are on the same team, each should respect the other. The primary purpose of the CDI is to query while the patient is in house and to look for clinical indicators or documentation that requires greater level of specificity. The coder is looking at the record retrospectively and sees the whole picture and applies coding experiences, rules and knowledge as well as facility guidelines.
Both CDIs and coders are integral to an effective CDI program. Peanut Butter and Jelly, salt and pepper, sun and moon. One without the other isn't as good as the pair.
1. I don't think it is the CDIs job to do retro reviews unless it is as QA process. Retrospective is usually the job of the coder.
2. If I was doing a retrospective review, I would probably refer it to the coding supervisor/lead for either education or query depending on policy.
3. If I disagree with the final DRG and can't reconcile it, then I will refer it back to the coder/coding lead for review. They have the final call. I do not push for a specific final DRG one way or the other. My job is to ensure the documentation is complete and accurate on a concurrent basis. Fortunately, we agree a vast majority of the time and probably on the rest it is a 50-50 split between changing to my DRG vs. keeping the original coder DRG.
I think creating a confrontational relationship between CDI and Coding should be avoided at all costs. Some of this can be managed through solid policy and procedures and job descriptions. It sounds like you have some good opportunity to promote some team building. Perhaps the questionable cases can be presented in a joint meeting of CDI and Coding and talked through. If that is not possible, then a policy should be created on how DRG discrepancies will be addressed/resolved.
Good luck!
My department is more than concurrent review - we are involved pre-bill
drop review.
Our process and agreement with coding is that charts with unanswered
queries, focused DRGs etc... are held for review until 11am next day.
This works for us - there is discussion, maybe an opportunity to clarify
again and we work together to "get it right".
Gail Marini MM, RN, CCS
Manager Clinical Documentation (CDI)
Finance Department
781-624-8413 (4:30am - 1pm)
B- 7757
Diane Draize RN, CPUR,CCDS
Clinical Documentation Specialist
Ministry Door County Medical Center
diane.draize@ministryhealth.org
920-743-5566 ex 3143
We earn trust by working together as One Ministry to keep PATIENTS FIRST in everything we do
2) If we miss a query opportunity it is up to the coder to follow up
with it.
3) If the CDI and Coder DRG conflict, the CDI specialist notifies the
coding manger who makes the final decision.
Greta Goodman
Clinical Documentation Improvement Specialist
Health Information Management
Virginia Hospital Center
1701 North George Mason Drive
Arlington, VA 22205
703-558-5336
ggoodman@virginiahospitalcenter.com
We work very close together. I am not a coder and have not taken
training to be a coder. If the coder and I have a discrepancy, we
discuss it and it works out in the end. We need each other!
If there is a retrospective query that needs to be done, I do these as
well. I have asked the advice of the coder to make sure I am within the
coding guidelines when sending a retrospective query.
Patti Stewart RN, BSN, Clinical Documentation Specialist
Usually I refer any charts to the Lead Coder and Coding supervisor. I let them be the last word if I have any questions regarding their coding. Because ultimately it is the Coder's initials on the chart.
NBrunson, RHIA, CCDS
2)
1. Chart reviewed by CDI and query placed by CDI (our queries are permanent part of record)
2. If patient is discharged prior to query being answered it is the responsibility of the CDI to get it signed within 14 days or chart will be billed
3. If coder feels additional queries are needed, they are responsible on the back end to submit them so deficiency can be assigned
Dawn
ONE THING I PICKED UP ON AND REALLY SEEMS DISTURBING:
"...a CDI here try to change the coder's final code,and then put query in the discharge record.." -- actually rather blown away by that, sounds like final coding is done and the CDI is seeking documentation to get the record to where they think it should be? From my view point (if I understand what you are describing there), would certainly be initiating some "professional career guidance" in a one on one private setting with that CDI. If that behavior is not rapidly resolved, the CDI would be at risk for continued employment with me as CDI Manager. Same for the "confrontational" behavior you described.
To address your questions:
1&2) Retrospective reviews -- we do some in the first 24 hours post discharge, especially when following up on something that was unclear or to ensure a query response. Additional later reviews may be conducted on an individual basis purely from an educational perspective -- how did this particular challenging case get coded out? Retrospective queries are conducted by the coding professionals when they feel there is a continued or newly identified need.
3) The CDI - Coding relationship needs respect & collaboration which allows ALL parties the chance to learn something and leads to the best documentation and coding to obtain accuracy and specificity.
I had done a blog post on this topic that you might want to read:
http://blogs.hcpro.com/acdis/2010/08/acdis-poll-illustrates-need-for-drg-reconciliation-process/
Don
Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com
Never give in. Never, never, never, never--in nothing, great or small, large or petty--never give in, except to convictions of honor and good sense. Never yield to force. Never yield to the apparently overwhelming might of the enemy
Sir Winston Churchhill
2. There are times when I am doing a chart audit on a current record when I see a missed query opportunity that could impact the case (DRG, severity, mortality) and a query will be done.
3. If we have an issue with a coded chart - we discuss it with the coder. If it is a serious issue we will forward the chart to our compliance manager for review and she will discuss the case with the coder if necessary.
Confrontation does not promote a positive respectful relationship with the coders. The process works best when everyone treats each other with respect.
Renee
Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center
Hang in there and perhaps your supervisor can review some of the articles that have been posted on CDI metrics and focus on those instead. After all, it's not the DRG that should matter, but a complete and accurate medical record.
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
At my current CDI position we are not allowed to have contact with the
coders. Prior to my arrival there was alot of bad interactions between
the coders and CDI. Very unfortunate. I presented information to the
leaders regarding that lack of communication and not making me accountable
to reconcile the coded DRGs You can state you are not a coder. Hopefully
that may help your situation. Present other metrics you can accomplish to
show your success with the program so the focus can move away from coding
and more to documentation improvement.
I am trying to mend this disconnect, but I know it will take time and
patience. maybe some grrr's at times.
But know you are not alone.
Stacy Vaughn, RHIT, CCS, CCDS
Data Support Specialist/DRG Assurance
Aurora Baycare Medical Center
2845 Greenbrier Rd
Green Bay, WI 54311
Phone: (920) 288-8655
Fax: (920) 288-3052
only return records for question/review when I see a mistake.... a missed
procedure, sequencing etc ........ we have some VERY new coders ..... they
are still learning. I believe we are another set of eyes for them
Thank You,
Susan Tiffany RN, CCDS
Supervisor Clinical Documentation Program
Guthrie Healthcare System
email: tiffany_susan@guthrie.org
"Twenty years from now you will be more disappointed by the things you
didn't do than by the ones you did do. So throw off the bowlines. Sail
away from safe harbor.Catch the trade winds in your sails. Explore. Dream.
Discover." Mark Twain