Who makes the ultimate decision?

What does your governing body look like when the CDI specialist and the coding group can't agree on the interpretation of a guideline? or the coding group can't even agree amongst themselves?

Some of the guidelines fall into the "gray" area (I bet this doesn't surprise anyone) and the coding group can be VERY black and white in their thinking and sometimes have trouble considering other perspectives. After exhaustive research with reputable sources there are timeswhen we are still at odds. Who makes the ultimate decision on organizational process as we strive toward greater consistency?


  • If there is no one within the coding group assigned as the decision-maker, then consider creating a Coding Escalation Team made up of individuals from CDI and coding positions and a physician, if possible. They would hear the arguments for each/every side (with documentation, official references, etc.) and either make a consensus on a final decision or send the question to the external authoritative body (AHA Coding Clinic, AMA CPT,, etc.). Keep a record of the Q/A on a shared drive for documentation and future reference.

  • We utilize a DRG Mismatch disagreement flow sheet

    CDI/Coding> disagree>both review> Still disagree then CDI has a 2nd level review> If CDI agrees with coding account finalized> CDI disagrees with coding Coding 2nd level review> If agreement is reached then account released> if no agreement account goes to coding advisory team and their decision is the final decision

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