CDI Process

hootstown

Good Afternoon,

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

morris-jeff@CooperHealth.edu

hootstown said:

Good Afternoon,

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

CDI Specialist and Coding Professionals are both bound by the Official Coding Guidelines and also should adhere to the AHIMA/ACDIS Query Practice Brief to ensure they are issuing compliant queries. Any information in the chart can be used to be supporting evidence for a query. If a wound care nurses states the patient has a stage 3 ulcer to their sacrum then you'd need a dx from the MD. 

Thanks,
Jeff

hootstown

Jeff, 
Thanks so much.  I was pretty certain that was the case, but I have heard physicians make comments that CDI's don't have to adhere to those guidelines as strictly, which I thought was kind of interesting.  Thanks for the sanity check.  
Laura

evanspx@sutterhealth.org

With all due respect, physicians are not experts in the realm of compliant documentation, coding, billing, auditing and CDI Best Practice.  I’d have to wonder why any MD would make such a comment that is so inaccurate.  Over my decades in this realm, I have heard many inaccurate statements made about the requirements for compliant coding and billing, and the resources Jeff cited are great reference.

Respectfully....

Paul Evans, RHIA, CCDS

hootstown

Paul,
I agree with you whole-heartedly.  I'm not sure why the comment was made, nor am I in the position to aske about it, but just wanted to make sure I didn't miss something somewhere in what I was taught.  
Laura

evanspx@sutterhealth.org

Thank you, and I totally understand.  Just wanted to state that in our profession there are sometimes flawed statements regarding proper coding and query content and it can be puzzling.  There are MDs, many, that obviously are experts in the realm of CDI and coding; but, over the years,  many involved in coding and HIM management and CDI have to cite regulations to auditors, physicians, CFOs and so forth.