I’m hoping I can get some clarification on the process of how CDI works. I’m working on a project at work and we are discussing how CDI specialists accomplish their goal of improving documentation. Coders generally query to get a more specified code and do this strictly on physician documentation. Coders shouldn’t pull up nursing documentation and random lab results and query for a diagnosis. Are CDI specialist given more leniency in querying or do the same rules apply to the query process as coders? For instance, how would a CDI specialist use information of a pressure ulcer and its stage in a nursing note that isn’t mentioned in any physician documentation? Would this nursing info be of any value, since it’s not physician documentation?
Thank you in advance for any insight shared,Laura